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Return to Throwing: A Rehab Program

by | April 2, 2014, 8:00am 5

Let’s say a college baseball player injures his shoulder pitching. After completing medical treatment, surgery, therapy, or some combination of the three, the orthopedist gives him a return to throwing program. A college ultimate player who does the same? An orthopedist asks him what ultimate is, prescribes treatment, then when treatment is complete, says “Ok, you’re good to go.”

I’m currently the strength and conditioning coach for the University of Central Florida Dogs of War, as well as a physical therapy student, and I frequently consult our guys on injuries. A guy on our team had had a nagging shoulder injury since before he joined this season. When he brought up the issue of his shoulder he told me he’d seen a doctor, had physical therapy, got an MRI, which came back negative, and had a cortisone shot, and still, nothing had fixed his shoulder in over two years. The pain came back every time he played. “What’s missing?” I asked myself.

I was working with a high school pitcher in my physical therapy clinic one day as a student intern. The kid had a labral tear and was absolutely killing his rehab program at 10 weeks post-operation. “When can I throw?” he asked. “Not until the doc clears it man.” When the follow-up appointment with his surgeon arrived, we gave him our progress note to take with him, and expected him to come back cleared. Nope. The doc said he couldn’t begin throwing until next month, and even then he could only start with an ultra-conservative throwing program. And this kid had been pain free for weeks.

Eventually I bridged the gap in my mind. Ultimate is a throwing sport, so why should we treat return to throwing in ultimate any different that we do in baseball?

So I came up with this return to ultimate throwing program. It’s based very loosely off of Kung Fu Throwing, which our team has been using for the past few seasons. It also uses principles in programs designed to get baseball players back to throwing, as well as programs for returning to running. It progresses in volume and distance in each phase, and progression (or regression) through the phases is based on your own pain response. The difference between baseball and ultimate is this: all baseball throws are overhead and involve internal rotation of the shoulder, whereas in ultimate most throws aren’t overhead and there’s a good mix of internal rotation (flick) and external rotation (backhand). I thought about doubling the volume for this reason but decided against it because external rotators act eccentrically to decelerate the shoulder during follow-through after a flick, and vice versa for backhands. For further explanation on this, here is a helpful article. It also includes some good supplemental exercises. After I made the program, I went back and added hammers since overhead throws are much different and need to be addressed as well. This is what I came up with:

Return to Throwing Program

Rules:

  • Do each stage a minimum of 2 times with no pain (during or after, typical muscle soreness is fine) before progressing to the next stage.
  • If there’s pain, stop and go back to the previous stage the next day
  • One stage per day

Procedure: Stage 1:

  • Stand 10 yards apart. Complete 15 flicks, 15 backhands, rest 2 min, repeat.

Stage 2:

  • Stand 10 yards apart. Complete 10 flick, 10 backhand, rest 1 min, repeat.
  • Stand 20 yards apart. Complete 15 flicks, 15 backhands.

Stage 3:

  • 10 yards. 5 flick, 5 backhand, 5 hammer, rest 1 min, repeat.
  • 20 yards. 15 flick, 15 backhand, rest 2 min, repeat.

Stage 4:

  • 10 yards. 5 flicks, 5 backhands, 5 hammers.
  • 20 yards. 10 flicks, 10 backhands, 10 hammers, rest 2 min, repeat.
  • 30 yards. 5 flicks, 5 backhands.

Stage 5:

  • 10 yards. 5 flick, 5 backhand, 5 hammer.
  • 20 yards. 5 flicks, 5 backhands, 5 hammers, rest 2 min, repeat.
  • 30 yards. 5 flicks, 5 backhands, 5 hammers, rest 2 min, repeat, rest 2 min, repeat.

Stage 6:

  • 10 yards. 5 flicks, 5 backhands, 5 hammers.
  • 20 yards. 5 flicks, 5 backhands, 5 hammers, rest 2 min, repeat.
  • 30 yards. 5 flicks, 5 backhands, 5 hammers, rest 2 min, repeat.
  • Hucks. 5 flicks, 5 backhands.

During all six stages, be sure to get a solid mix of outside-in and inside-out throws. You want to make sure you’re working and strengthening the muscles used for each.

I also strongly recommend incorporating the Thower’s Ten resistance training program. It involves strengthening to all the rotator cuff muscles as well as the muscles of the scapula. Imbalance or poor dynamics between the shoulder blade and the shoulder are often what lead to shoulder injuries in the first place. For each of these exercises, do high volume and low resistance. Finally, don’t throw and lift on the same day.

This program ended up working great for my guy. He took off all winter break, throwing only with his right (non-dominant) hand and performed rehab exercises included in the Thrower’s Ten on his left. When he began the current college season he continued to throw righty in practice, and began progressing through the program. He has had minimal pain since and has been able to return to full function.

Hopefully it’ll work for others out there too. I’d love feedback.

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5 Responses to “Return to Throwing: A Rehab Program”

  1. Leslie Wu says:

    Besides t-spine mobility, breathing drills, balancing pushing & pulling, possibly discouraging (bilateral / non-flat bar / incline) bench & overhead lifting (Eric Cressey), mindfulness of upper-trap dominance when lifting (also pulling) here's what I've been experimenting with lately for throwing shoulder (p)rehab:

    - Foam rolling lats and rotator cuff (lax ball for traps? not sure)

    - Rhythmic stabilization and/or the bottoms-up KB screwdriver: http://www.jeffcubos.com/2010/12/16/the-best-shou

    - PVC pec mobilization: http://michaelgrayfitness.wordpress.com/2011/03/3

    - Shoulder stretches including: http://www.sensational-yoga-poses.com/images/asan
    (also with elbow at 90)

    I used to do more KB get-ups and armbars, might try integrating that again.

    Also, what of throwing mechanics? I've been experimenting with using the shoulder-arm complex less for forehand hucks and instead using McGill's notion of superstiffness at the core and forearm/wrist (http://activespineandsport.net/uncategorized/super-stiffness/)–power generation comes from ground contact force, hips and shoulders but momentary tightness at the core then at the forearm/wrist tendons/musculature to bounce or spring-load the change in disc acceleration.

    [Plate pinch gripping for forearm muscle/tendon hypertrophy => increased RFD too?)

    #thoughts

    ~Leslie

  2. zollis zollis says:

    I'm definitely a fan of foam rolling and lax balls, especially in the traps and lats. Foam rolling is a pretty new thing and there's not much evidence on it at the moment but I'm anticipating there will be soon. Static stretching as a warm-up is slowly becoming more outdated (thankfully), and I think that in the future it will be standard to use rolling on tight, "cold" muscles to warm up, and stretching only for muscles that are actually restricted.

    That's honestly the first time I've seen that screwdriver/armbar. It looks pretty high level but I like it a lot! It definitely has a bunch of benefit from the neuromuscular perspective, giving the shoulder a lot of PNF-type action. Gets the serratus muscle well too, which often goes neglected.

    That PVC mob looks ok but I'd probably do it as a static stretch, 30 seconds or so. Play around with the angle too. Can do this stretch too with two hands (http://www.womenshealthmag.com/fitness/overhead-squat ) and incorporate a squat with it. That's part of the functional movement screen and most people cant hold the overhead position.

    Stretches are always good.

    I don't know anything about that McGill theory but it looks interesting. I'll look into it some more.

    Plate pinching would be ok but its isometric and not really sport specific. It wouldn't help RFD with a flick unless its concentric. If you're going to do isometrics for the hand flexors I'd say a hang board routine like rock climbers use would be better. Gives it more variety in position and neither are sport specific anyway. It would be higher level though.

    Great stuff, thanks Leslie!

    • Leslie Wu says:

      Yea I'm not sure about the connection between forearm strength/hypertrophy and huck distance but it's something I've been experimenting with lately.

      I've been curious why the above-average club player in the open division can flick huck deeper than above-average player in the women's division. Lever arms aside, studies do suggest strong differences in forearm musculature. So, would forearm hypertrophy be a building block in helping women flick past 50 yards more easily?

      Strength training for hypertrophy (more time under tension), although not sport specific, would help not only muscle mass but tendon hypertrophy & stiffness, both of which may be building blocks for deeper throws. Anecdotally this has made a notable difference in my lefty backhand, although of course you need to turn the building blocks into a skill by practice.

      I used to do more FatGripz and (overhead) hanging work with bars and towels but might try instead hanging from a supine rather than standing position to avoid the shoulder load. As a non-climber haven't done much work with the board but definitely a good thought!

  3. Alex Lszn says:

    I'm currently going through this program as (hopefully) the last part of my elbow rehab. I had multiple tendinoses and a slight nerve issue (climbing, judo and ultimate are all pretty unfriendly to elbows). Thank you so much for sharing it, fingers crossed it'll be what gets me ready to play in time for the club season, and I'll keep you updated.

    Having decided to do each stage for a minimum of three days, and not to move on until I recorded zero discomfort, I'm about to try stage 4 for the first time. I spent 3 days on stage 1, 3 on stage 2 and 5 on stage 3.

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