By Bob Alejo
Over the past few months (and my guess is because it’s off-season baseball training time), there has been no shortage of articles, quips, quotes, and attempts at wisdom trying to define what arm health means, along with the “real way” to train the arm for increases in throwing velocity and performance. More specifically, how to achieve shoulder health and performance for pitchers. There was a statement made on Twitter that push/pull balance is outdated. It was a statement too broad to make any sense at first glance. However, at second glance, with training methods and thoughts evolving, the statement became more of a question to be answered and then supported.
At the same time, I thought it fair to contribute my 35 years of experience with overhead athletes (national and international elite), and specifically call upon my time with pitchers at the Major League Baseball level (the Oakland As for 12 years) and NCAA level on a daily—not remote—basis. At the same time, you can’t beat good old-fashioned science.
In this article, I centralize my thoughts on the throwing athlete, while including all overhead athletes (volleyball, tennis, swimming) as references. The wise practitioner will look outside of the throwing shoulder and at overhead athletes in general, if they want a knowledge base wide enough—scientifically and as a practical matter—to come up with a solution, or at least some damn good hypotheses on shoulder health. I’m not a physician or physical therapist, so don’t expect me to use that style of monologue, although I will cite and quote them. Don’t be fooled by those giving descriptions that sounds like prescriptions. As I have said before, “It ain’t that hard.”
Let’s Get One Thing Straight
This conversation must have some context width even though we are talking specifically about muscular balance and health in the throwing shoulder. Frankly, all this talk about arm health with no mention of the rest of body is a bit humorous, and disappointing at the same time. Only one consistent thought and caveat must underpin every conversation that includes pitching, velocity, and arm health: For a pitcher, arm health and velocity is never about any one or two muscles, or any one method.For a pitcher, arm health and velocity is never about any one or two muscles, or any one method, says @Coach_Alejo. Click To Tweet
The ball is thrown from the big toe to the fingers and everything in between. It is a total body movement and contribution! In fact, there may be contributions from body parts during overhead athlete movements in ways that many of you reading this might not even know about. For instance, did you know: “The significant amount of muscle activity (assessed by maximal voluntary isometric contraction) elicited by the biceps femoris (125%) and gluteus maximus (170%) of the stride leg, eccentrically controls hip flexion deceleration and deceleration of the throwing arm that accompanies the follow-through portion of the pitch (Campbell et al., 2010)?”
Tip: If a strength program for a pitcher does not include pulling from the ground and/or one- and two-legged RDLs, expect less than the best results in shoulder health and performance. And don’t mutter under your breath, “So-and-so doesn’t pull from the ground or do RDLs, and is healthy and an all-star!” That’s a lazy response. A cop-out.
David Stodden, PhD, CSCS, has led and been involved with great research on pitching biomechanics and we have spoken at length about what happens when pitchers throw. He spent some time at the American Sports Medicine Institute (ASMI) and teamed with Glenn Fleisig of ASMI on a few research projects, and is currently a professor and the Interim Director at the Yvonne & Schuyler Moore Child Development Research Center. Stodden et al. (2005) summarized their study, “Relationship of Biomechanical Factors to Baseball Pitching Velocity: Within Pitcher Variation,” as such:
“…the effects of increased pelvis and upper torso rotational velocities (Stodden et al., 2001), trunk tilt forward at ball release, increased shoulder and elbow proximal force, increased elbow flexion torque, decreased horizontal adduction at foot contact, and changes in relative temporal parameters suggest that when a pitcher increased ball velocity, it was due to a more effective transfer of momentum in the kinetic chain.”
Campbell et al. (2010), scientifically states what we know is the obvious in the lower extremity during the pitching motion:
“Rotating the trunk and upper extremity requires a stable base of support upon which to rotate and, thus, simultaneous and substantial muscle activity from the stride leg and trial leg. This brief bilateral base of support serves to promote the optimal transfer of momentum generated from the initial phases of the pitch. Furthermore, during the later part of phase 3 (stride foot contact to ball release) and throughout phase 4 (ball release to 0.5 seconds after ball release), the stride leg musculature must eccentrically and dynamically control the ankle, knee, and hip joints as the trunk and upper extremities are decelerating.”
I’m not writing a science article, but the topic is based on science. It’s okay to be intellectual and a strength and conditioning practitioner at the same time. There’s no use in citing 10 more articles on what has been documented and what we should already know. Research like the ones cited are not rare in that they clearly talk about the entire body throwing the ball (implement) and include research as it pertains to field throws (javelin, shot, discus, and hammer).
By the way, have you heard about rotator cuff injuries in javelin throwers? They throw a weighted implement (heavier than a baseball) with analogous biomechanics to pitching, with a 30-40m run-up (more momentum than throwing from the rubber). It seems if something would break down, it would be under those conditions. Wonder why? Speaking of rotational performance, ever wonder why oblique strains are a rarity in the field throws? A ballistic, powerful, rotational throwing of fairly weighted implements, yet nothing. Could it be just plain strength and not medicine ball throws or planks? Think about it…a lot.
To be taken seriously or professionally, any person or organization interested as much as they say they are in arm health for pitchers must look at the entire body (kinetic chain). In this way, they leave no stone unturned. And by that, I mean assessing moderate-heavy loaded squats; deadlifts (pulls from the ground with shoulder blades pinched together; scapular retraction); vertical and horizontal pulling (180-degree plane); movement screens; anti- rotation/flexion/extension/ lateral flexion training; moderate to heavy loaded core training; baseline, analysis, and comparison of all the performance and training data from all the previously mentioned modes…just to name a few. Not to mention sleep and nutrition! Yes sir, it’s not easy or done with just one or two metrics.
Randomly Ordered Rockets off the Top of My Head Before I Get Rolling
In no particular order, I have a few points that immediately come to mind:
- Of the dozens of research abstracts (full texts unavailable to me in these cases) and full texts that I read about the shoulders of overhead athletes, muscular imbalance leading to injury or pain was listed nowhere as “pulling” muscles (antagonist, stabilizers, decelerators) overpowering the throwing musculature (agonists, accelerators) causing the imbalance or pain.
- It’s absurd to think that a healthy shoulder is maintained by light-load resistance training, band exercises, and 3-pound rotator cuff exercises alone! Those with common sense and knowledge of the game of baseball know that.
- It’s easy to forget that the scapula is one-half of the glenohumeral joint (glenoid cavity) and could be considered the greatest pivotal avenue for shoulder health for one reason: If the head of the humerus essentially stays centered in the glenoid (the scapula “stays”; strength-based) during the entire phase of throwing, then you are golden! It just so happens that the typical and likely most effective way to strengthen scapular movement and stability is through “pulling” exercises.
- Push-pull balancing remains a relevant training approach. Insensitivity to this philosophy is a risky proposition. We all know that push-pull balance means not only the amount of pulling exercises versus pushing exercises, but also the balancing and contribution of the accelerators, decelerators, and stabilizers to shoulder health. Work in this area clearly illustrates that balance is necessary for performance and health, as does the science, intuition, and common sense.
- Of the dozens of abstracts and papers I’ve read addressing the topic of concentric to eccentric ratios, nearly all of them state that the ratio was low due to the low eccentric strength in the dominant arm.
- Balance, imbalance, and strength ratios (eccentric:concentric) are consistent and common terms when looking at antagonist and agonist overhead studies on performance and injury as they relate to the shoulder.
Is Shoulder Balance a Push/Pull Thing?
Absolutely, and I’ll tell you why. First, let’s look at what push/pull is and where it came from. That’s an easy one—common sense and deductive reasoning, really. There exist two primary threads of thought in the strength and conditioning world, yet most philosophies hold both premises, not just one.
The first supposition counteracts repetitive movement. Basically, why would we have them do more of what they already do? There are hundreds of repeated patterns. Pitchers pitch over and over in the same way, swimmers perform the same stroke mechanics repeatedly, outside hitters swing hard at the net the same way, tennis serves and overhead strokes are similar. Batalha et al. (2015), summarize the result of repetitive motion in their paper’s abstract:
“In competitive swimming, the upper-body force needed to move the swimmer through the water, especially in the execution of 3 of the 4 strokes (freestyle, butterfly, and backstroke), derives primarily from shoulder adduction and internal rotation (IR). Thus, shoulder internal rotators and adductors become stronger and hypertrophied relative to their antagonist muscle groups.”
Yep, doing the same sporting motions repetitively (everyday practice and games) will make you strong in that direction and comparatively weaker in the other. It’s not a made-up notion. So, to focus on training all the muscles in the front of the throwing shoulder plus internal rotation would be “pattern overload,” causing an even greater strength discrepancy between agonist and antagonist, while increasing the risk of pain or injury. Ergo, let’s go in the other direction.
Do train both prime movers and stabilizers, but focus on performing more work on the antagonists to strengthen them to offset the amount of work the agonists already do. Here, look at Niederbracht et al. (2008), who do a better job explaining this than I do:
“…by increasing the eccentric external total exercise capacity without a subsequent increase in the concentric internal total exercise capacity, this strength training program potentially decreases shoulder rotator muscle imbalances and the risk for shoulder injuries to overhead activity athletes.”
The second common thought regarding the balance of pushing and pulling exercises is based on injury and eccentric contraction—lengthening of a muscle against a heavy load or lengthening at high speeds usually as a result of an agonist(s) during a movement. Or, to put it in weight room terms: In pitching, it’s having the back of the arm/shoulder strong enough to withstand the strength of the front! The main thought years ago was that injuries happened during or because of decelerating motion; however, I think the definition has specifically widened to include eccentric movement.
To be fair, phases 3 and 4 during pitching (the deceleration phase mentioned earlier) have been shown to have the highest risk and incidence of injury. No surprise there—it’s also when the highest muscle activity occurs. Also, the term “deceleration” is used in lieu of “eccentric” in current literature, as is the case in “Prevention of shoulder injuries in overhead athletes: a science-based approach” (Cools, A.M. et al., 2015): “These muscles (external rotators) function as a decelerator mechanism during powerful throwing, serving, or smashing.”
Again, based in part on the amount of repetitive movement and the theory that hamstring:quadriceps strength ratios correlate to hamstring injury—although there is some conflicting current information today, such as Beardsley, C., Frackleton, G., et al. (2013)—coaches hypothesizing that performing more pulling exercises than pushing exercises (more back of the shoulder than front of the shoulder exercises) made sense. However, to date there has been nothing conclusive as to what exact push:pull set/rep/load ratio per workout, meso- or macrocycle is best. Nor is there any agreement on the perfect strength ratios of the internal and external rotators or concentric internal rotation and eccentric external rotation. Still, coaches have used a few combinations (1:2, 2:3, 2:4, 3:4).
Wilk, K. E. et al. (2009), presented the idea that “proper balance between agonist and antagonist muscle groups” provides dynamic stability to the shoulder joint. He also stated that proper balance of the “glenohumeral joint external rotator muscles should be at least 65% of the strength of the internal rotator muscles.” (Wilk, K.E. et al., 1997) Other researchers have given their take on internal/external rotator muscle balance, but I chose Kevin Wilk (PT, DPT, FAPTA) because he has studied this extensively. In the same 2009 study, Wilk states, “…the external-internal rotator muscles strength ratio should be 66% to 75%.” (Wilk, K.E. et al., 1993; Wilk, K.E. et al., 1992; Wilk, K.E. et al., 1997) Whether these numbers are the case or not is not the point; they provide a stake in the ground that reflects that balance and ratios are, in fact, important.
Mike Reinold (PT, DPT, SCS, CSCS) explained to me, from a clinical perspective, how he thought some of this came about. The idea of changing the way the shoulders were trained was simpler from a surgeon’s standpoint. Doctors were looking at the torn rotator cuffs of throwers and noticing that all the shoulder complexes in those surgeries had identical pathology. So, simply stated, if shoulders being operated on all looked the same, then the opposite should mean a healthy shoulder! But the problem, as Mike said, is that the shoulders of good, healthy players look the same as those who need surgery. That’s interesting and, when you think about it, very true.
The Scapula Is a Great Place to Start Enforcing Shoulder Health and Performance
Most of the work on clean shoulder function of the overhead athlete (e.g., Park, K-M et al., 2014) mentions the scapula, and the words “balance,” “imbalance,” and “ratio.” I really think this is lost on most coaches and, if I catch myself, I find that I focus on the shoulder and pulling strength and lose sight of the intent of shoulder function, which is to stabilize the scapula during throwing/overhead movements.
In my conversations with them, both Reinhold (his research) and Rob Panariello (PT, ATC, CSCS, and founding partner and chief clinical officer of Professional Physical Therapy) were clear on the importance of scapular stability and strength. Panariello feels that building a base of stability in the shoulder comes from strength, and that the head of the humerus stays in the glenoid because of strength. My personal philosophy is that strength is the basis for all performance. So, he had me convinced when he implied that an early, solid strength program covers it all. But what he said next was as important. He told me that training the humerus to quickly center is an important piece as well, especially after injury; training that involves high accels/decels, tempo, and perturbation of the shoulder is necessary for that adaptation. As in training, we must establish a foundation before specialization occurs.
Let’s look at what makes the scapula move…or not. The primary muscles that control scapular movements are the scapulothoracic muscles: the trapezius, serratus anterior, levator scapulae, rhomboids, and pectoralis minor (Reinhold, M. et al., 2009). I often mention the trapezius, serratus anterior, and rhomboids in my reviews of the literature for maintaining balance and health, as in Rasouli, A. et al., 2017. As most of the studies on the topic indicate weakness, fatigue, injury, or, as Reinhold implies, when “normal patterns are disrupted,” many believe this leads to shoulder (glenohumeral) injury. It’s clear to me that for the shoulder alone, the scapula is the focal point of health. If the scapula can move or resist poor movement through strength and stability, then the cuff stands a better chance of being pain-free.Scapular movement and stability through strength will cure a lot of shoulder problems, says @Coach_Alejo. Click To Tweet
In the end, while the rotator cuff is a point of interest and sometimes the focus, I say that scapular movement and stability through strength will cure a lot of shoulder ills.
So, What Do We Do?
What I’m doing here is not a meta-analysis or systematic review. I’m just a guy reading a ton of research, talking to experts on this topic, and sprinkling my experience into the manuscript. However, the evidence is overwhelming in regard to a few things. These are my recommendations based on the literature.
Balance Pushing and Pulling
Carter, A.B., et al., 2007; Niederbracht, Y., et al., 2008; and Wilk, K., et al., 2009—to name just a very, very few—mention ratios and balance. Nearly every like study or article states the balance and ratio of antagonists and agonists or eccentric and concentric strength in throwing kinetics. We always look upon imbalance as the injury culprit. The structure is already out of balance—the dominant shoulder does many times the amount of work going anterior than going posterior. Consequently, because backside musculature is at a deficit to begin with, and nowhere has anyone documented anecdotally or in the science where the scapulothoracic muscles overpower the throwing motion, causing shoulder abnormalities or injury, sensitivity to push/pull balance is critical by deduction. In fact, you could suggest that if the scapula is in good shape, the cuff will be of little worry.
The question is, what ratio are we looking at? I recommend a 1:2 push to pull ratio. Honestly, I usually programmed a 2:3 or 3:4 depending on body type, pitching mechanics, and medical history. Typically, it was unnecessary to stray from that template based on a performance and health standpoint. That method will cover the overwhelming majority of overhead athletes. But now that I’ve done this science-finding mission, I’ve changed my mind. This is because I see the research leaning heavily on scapulothoracic musculature and the amount of evidence from other overhead studies of overworked sporting movements.
While we talk about the rotator cuff in terms of external and internal rotation, and ratios and imbalance, the discussion on scapular placement and movement during throwing is a more focused and in-depth commentary within the literature. When I read several comments like this one in Oliver, G., et al. (2016), everything becomes clearer to me: “In throwing athletes, proper pelvis and scapular positioning are vital to the overall function of the shoulder as kinetic energy is transferred from the lower extremity through the pelvis, trunk, and scapula onto the shoulder (Kibler, W.B., et al., 2013).” Despite any success I had training the “game’s” finest pitchers, perhaps I undertrained the pulling portion of the programs. The musculature most involved in deceleration and scapula strength and stability could have been better, in my new estimation!
One last note on the scapula—the deadlift! It is by far the most underrated scapular retracting exercise for strength and rehabilitation after injury. Not only is it great for lower body strength, but pulling from the ground, with the scapulas pinched together, is a challenge that the scapula must overcome, particularly and intentionally with heavy weight. As I’ve said many times before, steering clear of heavy weight (90-100% intensity) is a mistake for any sport and has been an unjustified stigma in baseball since weight training’s introduction into the game. Just so we’re clear, heavy weights come after an athlete’s technique is competent and they acquire strength as a result of a background of repetition volume. The fear of heavy deadlifting in baseball should only come from two things: the athlete is not prepared for it or the coach can’t teach and program it.The #deadlift is the most underrated scapular retracting exercise for strength and injury rehab, says @Coach_Alejo. Click To Tweet
How do you do 1:2 ratio? Easy. Do the math. Add up the sets and reps? Well, not really. You see, not all pushes and pulls are analogous. A chest press is not the equivalent press to an overhead latissimus pulldown; it doesn’t cover the same angles, region, or range of motion. This is the reason I created the training style, “Reciprocal Training.” Same plane, same grip. The thumbs-facing-in grip of the flat bench press corresponds to a seated row with the same grip and same plane; a thumbs-up dumbbell front raise corresponds to a thumbs-up straight arm pullover or pulldown; and a reverse barbell curl (palms facing down grip) pairs up with a same-grip tricep cable pushdown. You get the point.
Then it is a matter of sets and reps. In this case, balance would be the same intensity as well. In other words, when in a strength cycle (sets of five repetitions), the paired exercises would both be performed for the same repetitions and maximum poundage. Also, if there are three sets of bench presses (working sets) then there are six sets of rows. It sounds like a lot, but the research intimidates me a little on that side. It certainly should grab your attention.
Pull in a 180-Degree ROM
As Stodden asks, “How can we say we need a balanced attack on the shoulder but not pull—or press, for that fact—past 90 degrees?” The answer is that we can’t! If I want to stabilize the scap every way possible, I want to pull (retract), elevate, and upper rotate every possible chance to counteract the powerful forward movement of pitching. That being said, how can we talk about balance and ratios and not pull in a 180-degree range?! If you don’t, then you do not subscribe to training in a full range of motion (ROM). This is a curious philosophy when you consider that injury risk is higher when there is weakness at any place during an active range of motion; particularly at an extreme ROM (fully extended or fully flexed).
I recommend one- and two-arm movements for all vertical pulling. For example, horizontal rows with emphasis on “pinching” the shoulder blades together at the finish of the pull, and definitely reaching out as far as the shoulders can stretch forward (not a toe-touching move) before the next pull. Reaching forward is a technique that most athletes avoid, and it’s a mistake. This reach forward helps to maintain flexibility and strength in a similar position to the follow-through in pitching—the phase most stressful to the arm; the phase where most arm problems show up and a range of motion where the rhomboids can be trained optimally.
Vertical rowing (upright rowing) is important as well, given the importance of the trapezius in maintaining scapular placement and movement. One exception is that I do resist the idea of most two-arm grips narrower than shoulder width. This narrow grip exposes the humerus, specifically the head of the humerus, to a stressful position (concentrically and eccentrically) that is uncommon for most people, especially a pitcher.
Train for Great Lower Body Strength
This is nothing any beginning strength and conditioning coach does not know: The legs provide the conduit for the display of force by the upper body. And it’s always good to have good supporting info even if it’s elementary. I’ll start with this: In a meta-analysis (compiling research on a topic and combining the subject population and running statistics on a larger sample size for statistical significance) of ball velocities and overhead athletes, Myers, N.L., et al. (2015) suggests that “…these athletes use the entire kinetic chain combining multiple anatomical segments and regions to generate force in a proximal to distal fashion.” Not ironically, the programs in the meta that did not find any significant increases in ball velocity “were relegated to upper body” exercises.
Looking at the gluteal muscle group activation and throwing motions of softball position players, Oliver, G.D., et al. (2013) is more than clear that for “…throwing athletes, proper pelvis and scapular positioning are vital to the overall function of the shoulder…,” while the energy of the motion transfers from the lower body “…through the pelvis, trunk, and scapula onto the shoulder.” Oliver, et al. (2016), is again clear by reiterating what we already know: “It is known that pelvic stabilization is needed for essential scapular function…,” going on to cite original research and later to explain that both single and double leg support are important for upper extremity performance. Actually, there are a few other good lumbopelvic studies pointing to increases in shoulder load when there’s a decrease in energy generation from the hip complex (Gilmer, G.G., et al., 2017). Evidently, and I’m sure there are plenty of other studies pointing to the same conclusion, lower body strength is not only important for delivering the force through “the chain,” but is critical for scapular positioning and function.If you are an overhead athlete, train your lower body for strength and power, says @Coach_Alejo. Click To Tweet
Now for some plain folk talk. Here it is—If you are an overhead athlete, train your lower body for strength and power so the upper body can perform at the best possible level. Specifically, for pitchers a strong lower body will influence scapula positioning and therefore improve shoulder health and likely decrease stress on the elbow. Make no mistake: If your athlete is of college age or older, 10-pound kettlebell RDLs or 40-pound goblet squats won’t cut it. Use heavy weights (+85% intensity) and get strong!
Train with Two Arms
Research regarding non-injured swimmers shows there is no significant difference in shoulder flexibility, strength, or ratio between the two sides (Wang, H.K., et al., 2001). We know there will be a strength difference between arms of a unilateral dominant athlete, but how much is too much? What I’m getting at is that I found an interesting study by Noguchi, T., et al. (2014) that suggested “…maintenance of imbalanced strength and muscle tone between the upper limbs has been reportedly correlated to glenohumeral joint disorders.”
It is not the only study to point this out. Of course, asymmetry between shoulders in pitchers is a fact and the symmetrical difference will most likely increase with age and participation. What I got out of these papers is that you should cover your bases (pun intended) in the injury management column and use both arms on a bar (bench press, lat pulldowns, rows, curls, etc.) while mixing in dumbbell work. There is no need to separately train each arm with separate loads and volumes or to always use dumbbells.
Are we looking for symmetry in the overhead athlete’s shoulders? Probably not, according to the conversations I have had with the aforementioned experts and from my own years of observation. It’s a highly unlikely strategy for optimizing performance in unilateral sports. But the two-arm approach is a good plan, forming a hypothesis from all the research on the topic.
Don’t Avoid Exercises
“What you resist, persists,” as my wife likes to say to her clients, and there is a parallel here. The avoidance of exercises for no good reason gets you nothing. Let me dispel a myth: At the risk of sounding draconian, there is hardly an exercise that a pitcher/fielder cannot perform under a supervised, well-thought-out program with an intent towards performance. I don’t know of one documented incident—studied or anecdotally—that has proven an exercise unworthy for a baseball or overhead athlete.I don’t know one incident that has proven an exercise unworthy for a baseball or overhead athlete, says @Coach_Alejo. Click To Tweet
In other words, an athlete performed an exercise and their sports performance decreased over time, or an athlete performed an exercise and it was proven to be the primary cause for their injury while throwing. Avoiding exercise because of a stigma and not scientific information, well, you know the typical outcome. No weight training program ever ruined an overhead athlete’s career. Though a poorly designed, supervised, and implemented program can end one in one day! However, with a healthy, functional athlete, if you avoid an exercise because you think it will cause injury, it’s possible that you might create one.
To use a term from the seventh grade (in 1970): Duh! Of course, “well thought out” means a you’ve performed a physical assessment of the athlete, indicating what methods are appropriate and safe.
The Beardsley article I talked of earlier has some interesting information about eccentric training. I admit, I have done little eccentric strength training in the past for pitchers, but that changes today! My pitchers did lift heavy in literally every exercise, from bench press to squat to reverse arm curls and, while I felt they were the strongest in baseball, I can comprehend now that the eccentric strength wasn’t where it should have been for the shoulder complex. In short, regular weight training techniques increase eccentric strength but not the way eccentric training does.
To me, performing an exercise slow eccentrically is not eccentric training. That’s accentuating the eccentric. That’s different. And I agree with Panariello: If it’s slow in any direction, it better be heavy. If you aren’t strong, how will you be strong at high speeds, such as in deceleration? If you try to counteract the dynamic, high speed force and deceleration of throwing by performing slow eccentrics with light weights (say, <80%), what is your thinking?! It doesn’t make any sense at all. Rehab-ish exercises and loads are not performance training; therefore, use weights at 90% or above, and low repetition (three to five reps) for eccentrics. That goes for pulls and presses. Keep remembering that pitching is a dynamic event!
Kevin Wilk has published and presented on the topic of shoulder health many times over the years, and I cite him five times in this article. During my review of this topic, I ran into this video titled, “The Throwers Ten Program,” developed by Kevin and Dr. James Andrews (American Sports Medicine Institute). The video speaks for itself. Here is the key to what Kevin offers; it’s organized and sound, and a regiment for throwers should include it.
It is up to the S&C practitioners to decide how to implement it and when. Erase from your mind any doubt that it works. Most of the exercises have stood the test of time, along with a few more recent ones. Now, this doesn’t mean that intense weight training, balance in the shoulder, and conditioning are not as important. They are. However, as the literature says, the rotator cuff work is a bit easier and less complex to attack than the overall musculature in the shoulder. This also means that these tubing exercises will isolate certain parts of the cuff that general strength work sometimes might not.
What Does This All Mean?
Thanks for your patience while devouring this piece. It’s lengthy, and I don’t think that we in the strength and conditioning world spend enough time dissecting old topics the way that I have done here. To summarize what I have talked about:
Even though I looked at studies of overhead athletes—and not exclusively baseball pitchers/throwers—the story and, more importantly, the summary of the data, were nearly identical every time. Imbalances and poor strength ratios (favoring the agonists) in the musculature of the shoulder lead to pain and injury.
The entire body contributes to shoulder health and performance in overhead athletes. Therefore, emphasizing any one body part in the kinetic chain is a poor method for injury reduction or better performance. Specifically, the lower body is integral in the delivery of strength, power, and overall energy through the kinetic chain to the pitch, spike, and throw.
The scapula appears to be the focal point of shoulder health even though the rotator cuff is often targeted. Proper and efficient positioning and movement of the scapula during shoulder movement can decrease the chance of rotator cuff pain and injury, thereby improving performance. There is evidence to suggest elbow health relates to scapular activity.
Push-pull balance in the shoulder is relevant and S&C coaches should be sensitive to the issue for overhead athletes. Based on the evidence and common sense, it’s likely that pull volume should be significantly higher than pressing volume (I recommend a 2:1 ratio) to reduce the risk of poor shoulder function, pain, and injury.
As long as an overhead athlete is healthy, there are no exercises that they can’t perform. Also, there is no information that points to limiting range of motion while exercising or weight training.
Eccentric training, not just a slow lifting tempo with light weights, would seem to benefit the overhead athlete, given the poor ratio of eccentric (deceleration) strength to concentric strength during arm movements.
- Beardsley, C. “Why does eccentric training help prevent muscle strains?” Strength and Conditioning Research
- Batalha, Nuno M., Raimundo, Armando M., Tomas-Carus, Pablo, Marques, Mário A.C., Silva, António J. “Does an In-Season Detraining Period Affect the Shoulder Rotator Cuff Strength and Balance of Young Swimmers?” Journal of Strength & Conditioning Research, 2014.
- Campbell, Brian M; Stodden, David F; Nixon, Megan K. “Lower Extremity Muscle Activation During Baseball Pitching.” Journal of Strength & Conditioning Research, 2010.
- Carter, A.B., T.W. Kaminski, A.T. Douex Jr, C.A. Knight, J.G. Richards. “Effects of high volume upper extremity plyometric training on throwing velocity and functional strength ratios of the shoulder rotators in collegiate baseball players.” Journal of Strength & Conditioning Research, 2007.
- Cools AM, Johansson FR, Borms D, Maenhout A. “Prevention of shoulder injuries in overhead athletes: a science-based approach.” Brazilian Journal of Physical Therapy, 2015.
- Escamilla RF, Andrews JR. “Shoulder muscle recruitment patterns and related biomechanics during upper extremity sports.” Sports Medicine, 2009.
- Fleisig GS, Andrews JR, Dillman CJ, Escamilla RF. “Kinetics of baseball pitching with implications about injury mechanisms.” The American Journal of Sports Medicine, 1995.
- Freckleton, G., Pizzari, T. “Risk factors for hamstring muscle strain injury in sport: a systematic review and meta-analysis.” British Journal of Sports Medicine, 2013.
- Gilmer GG, Washington JK, Dugas J, Andrews J, Oliver GD. “The Role of Lumbopelvic-Hip Complex Stability in Softball Throwing Mechanics.” Journal of Sport Rehabilitation, 2017.
- Kibler WB, Wilkes T, Sciascia A. “Mechanics and pathomechanics in the overhead athlete.” Clinical Sports Medicine, 2013.
- Kugler, A.; Kruger-Franke, M.; Reininger, S.; Trouillier, H.H.; and Rosemeyer, B. “Muscular imbalance and shoulder pain in volleyball attackers.” British Journal of Sports Medicine, 1996.
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