What's the Best Intervention to Stop the Tommy John Epidemic?

I am unapologetically becoming the "baseball guy" with my elbow, wrist, and hand discussion post today. With my past and present experiences in the game, I am naturally curious about the ulnar collateral ligament (UCL) and any precursors or warning signs affiliated with pathology of the aforementioned ligament. We have a pretty thorough assessment process with our baseball athletes and have done a fairly good job of avoiding a large number of tears/sprains in our youth and college populations. 

I was unable to find any research evidence suggesting that anatomical markers like shoulder flexion deficit, glenohumeral internal rotation deficit and total range of motion asymmetry are directly correlated to an increased risk of pathology of the UCL of the elbow, even though I have always operated under these presumptions. There is plenty of evidence to suggest that these markers are linked to increased likelihood of "injury in overhead athletes," just not the UCL specifically. 

I've used the Functional Movement Screen and Y-Balance Test as staples in our assessment process at my gym for a number of years now so I was excited to find that in a study (Garrison, Arnold, Macko, Conway, 2013) published in The Journal of Orthopaedic and Sports Physical Therapy baseball players with UCL tears displayed significantly impaired balance on their lead and balance legs when measured with the Y-Balance Test. This is important information in my opinion because it suggests that training the lower extremity and core is as important, if not more important than focusing on popularized "prehab" and "shoulder care" work. I'm excited to know that these are numbers we should probably be looking at more closely in our baseball populations.

It is my opinion that the best way for us to prevent the increasing frequency of UCL tears is to try and have some kind of influence on coaches at the youth level. A study published in the American Journal of Sports Medicine in 2016 found that in baseball pitchers aged 12-18 the mean UCL thickness was 4.40 mm in the dominant elbow and 4.11 mm in the non-dominant elbow. (Atanda, Averill, Wallace, Niiler, Nizarian, Cicotti, 2016) This suggests that baseball players are already beginning to make structural changes to deal with the stresses of throwing at a young age. Furthermore, the study found that the UCL was significantly thicker in pitchers who threw more than 67 pitches per appearance (4.69 vs 4.14 mm), who pitched more than 5 innings per appearance (4.76 vs 4.11 mm), and who had more than 5.5 years of pitching experience (4.71 vs 4.07 mm; P < .001). Linear regression demonstrated that age, weight, and pitches per appearance (R2 = 0.114, 0.370, and 0.326, respectively) significantly correlated with UCL thickness. (Atanda, Averill, Wallace, Niiler, Nizarian, Cicotti, 2016)

This information would suggest to me that pitchers who are taking on large work loads at a young age are experiencing the negative consequences earlier than those who are not forced to throw as often. I think the best way to lessen the severity of the "Tommy John Epidemic" is to get our youth baseball coaches to stop overthrowing their best players. Putting more influence on player learning and development and less on winning games would be a great way to ensure these athletes are able to play baseball for as long as they so choose without having to go under the knife. 

All that said, I would be interested to hear any input or findings some of you may have suggesting there are more anatomical markers for predisposition to ulnar collateral ligament pathology. 

References:

Atanda A, Averill L, Wallace M, Niiler T, Nizarian L, Cicotti M. (2016). Factors Related to Increased Ulnar Collateral Ligament Thickness on Stress Sonography of the Elbow in Asymptomatic Youth and Adolescent Pitchers. American Journal of Sports Medicine, 44(12), 317. 

Garrison JC, Arnold A, Macko MJ, Conway JE. (2013). Baseball Players Diagnosed with Ulnar Collateral Ligament Tears Demonstrate Decreased Balance When Compared with Healthy Controls. Journal of Orthopaedic and Sports Physical Therapy. 43(10), 752-758. doi:10.2519/jospt.2013.4680

The Role of Evidence Based Practice in the Fitness Industry

In my experience, the majority of fitness professionals to date have constructed their methodology entirely from anecdotal evidence and opinions. I’ve worked as a human performance professional now for around eight years. I started at a commercial gym as a performance coach for young athletes along with doing some personal training with the general public. Around four years ago I decided to jump into entrepreneurship and open my own gym. One thing I’ve learned in my experience working with both young athletes and adult clients is this: You better have a reason why you are doing everything.

If you prescribe an exercise, any exercise, you had better know why and be able to articulate that to your athletes or clients. If you cannot, you just simply won’t last very long in the industry. People are getting smart, and they want to know why certain methodologies are being applied and why others are not. If our health care system doesn’t change and preventative medicines like professionally guided exercise and nutrition don’t eventually become socially subsidized people are only going to want access to more information about what they are paying out of pocket for. Fitness professionals have to be prepared to provide it. Having your practice based off current research and evidence will be the only way to do so.

To date, the group that has done one of the best jobs of providing a large pool of evidence to support their methods and providing a framework for professionals to implement those methods is the Functional Movement Systems (FMS) group. Implementing the FMS to help guide us through exercise selection and corrective exercise application at my gym has not only helped us to establish credibility as fitness professionals, but has vastly improved our ability to serve our athletes and clients.

According to the systematic review in our required reading, “Do evidence-based guidelines improve the quality of care?” by Bazian Ltd: Having guidelines to help us make decisions only improve the quality of care if they are implemented consistently and correctly. Some fitness professionals may be apprehensive about using a framework of guidelines to make decisions for fear of removing the “human element” or the process becoming too boring for the client. What I’ve found, is that most of your clients won’t mind if the end result is a desirable one. Furthermore, the ability to gather information, have a large pool of evidence suggesting to us what that information means, then parlaying that information into professional decisions actually frees us up to coach more instinctively.

I foresee the role of evidence based practice in the fitness industry being the only way to sustain a career and professional credibility. As preventative medicine becomes more important to societies with increasing health problems fitness professionals are well positioned to sufficiently expand their role in the health care system. Having your practice grounded in objectivity will likely be the only way to ensure you don’t miss out on the opportunity.