[Physio Discussed] Throwing injuries: load management, performance and risk with. Professor Tim Gabbett and Dr Mike Reinold

In this episode, we discuss all things “throwing injuries”. We explore: 

• Load management and the bodies response to load
• Signs of overload/fatigue vs development in athletes
• Acute:Chronic Workloads
• Balancing performance and injury risk
• Programming a modern throwing program
• Avoiding acute loading spikes in elite sport

This episode is closely tied to Mike’s case study he did with us called “UCL injury in a Baseball Athlete”. With case studies, you can see how top clinicians manage real-world cases and apply their strategies to get better results with your patients.

👉🏻 Watch Mike’s case study here with our 7-day free trial: https://physio.network/GabRei-CaseStudy

Dr. Mike Reinold is a globally recognized expert in physical therapy, sports medicine, and performance, specializing in rehabilitation and injury prevention for athletes, particularly baseball pitchers, while also helping people of all ages return to activity. He is co-founder and president of Champion Physical Therapy and Performance in Waltham, MA, and has extensive experience with Major League Baseball, including the Boston Red Sox, Chicago Cubs, and Chicago White Sox, where he developed programs to prevent injuries and optimize performance. 

Professor Tim Gabbett has over 30 years experience working as an applied sport scientist with athletes and coaches from a wide range of sports. He holds a PhD in Human Physiology and has completed a second PhD in Applied Sport Science, with special reference to physical demands, injury prevention, and skill acquisition. Tim has worked with elite international athletes over several Olympic Games cycles and continues to work as an advisor for several high performance organizations around the world. 

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Our host is @sarah.yule from Physio Network

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Transcript

Introduction

SPEAKER_01 0:04

What constitutes an appropriate response to loading in a throwing athlete? How do you assess whether a thrower is genuinely adapting to load versus beginning to accumulate fatigue or move towards maladaptation? And what are the key signs a throwing athlete is adapting well, and perhaps the early red flags when they're not? Today we explored all of this and more with two world-leading voices. Tim Gabbitt is an internationally recognized applied sports scientist with a PhD in human physiology and a second PhD in applied sports science, with over 30 years' experience working with athletes and coaches across elite and professional sport. Tim is known for his practical, common sense approach to high performance, translating complex research on training load, adaptation, and injury risk into coach-friendly strategies that work in real-world environments. Tim has published over 300 peer-reviewed articles and continues to consult globally across sports, including baseball, American football, rugby, basketball, cricket, and Olympic programs. We're also joined by Mike Reynold, who worked as a physical therapist, athletic trainer, strength and conditioning coach, and performance enhancement specialist for over 20 years. Working with organizations such as the Boston Red Sox, the American Sports Medicine Institute, and Massachusetts General Hospital, he co-founded Champion Physical Therapy and Performance in Boston and is widely regarded as a leader in throwing athlete rehabilitation and performance. In addition to his clinical work, Dr. Reynold has made significant academic contributions through laboratory and biomechanical research and global clinical education, teaching thousands of clinicians worldwide, and publishing over 50 journal articles and book chapters in leading journals, including the American Journal of Sports Medicine and the Journal of Sport and Health Science. Across this conversation, we'll unpack what appropriate adaptation really looks like in throwing athletes, how to interpret common changes like range of motion loss and fatigue, how to manage load in unpredictable seasons, and how to learn to read the signs an athlete is adapting well. You're going to love today's episode. It's packed with clinical gems. I'm Sarah Yule, and this is Physio Disgust. Well, welcome to you both, Tim and Mike. Thanks so much for joining us on the podcast today, talking all things throwing injuries. What we might do is get straight into it, exploring the concept of modern load and adaptation. So

What is Load?

SPEAKER_01 2:32

I'll start with you, Tim. Based on your recent work for a throwing athlete, what constitutes an appropriate response to loading?

SPEAKER_02 2:41

I guess the answer probably starts with a question back to you. What do you mean by loading?

SPEAKER_01 2:46

Oh, this is well played by you. I suppose loading is any form of, without using the word load, load through a joint or a soft tissue structure, any form of repetitive activity, any force that's going through any of our structures, be it bone or soft tissue.

SPEAKER_02 3:04

That's a pretty good definition to start with. I guess the next question then is, or the next way of looking at it is not all load is going to be created equally. Right. So when we talk about the appropriate response to load, then w we need to consider well, what is the load that's being applied? Let's think about throwing. If we're doing short toss or we're doing long toss, or we're on the we're in a bull pander on the mound, the type of load that's going through the shoulder and going through the arm, going through the elbow, is going to be completely different between those among those four different throws. So if that if the load is completely different, then the response is going to be completely different, or you'd expect the response to be completely different. So a response to short short toss it it could be considered, and Mike could jump in here. Short toss could be just the kind of thing that's low stress activity. You probably do more higher volumes of that loading, and you can probably do it more frequently. When you're getting someone on the pitching mound, or you're putting them in the bullpen, or you're doing hard throws, then the response to that load is going to be completely different, and you'll probably do it less frequently. There'll be probably a little bit more inflammation, there might be some uh reductions in range of motion temporarily, there might be some soreness, there might be some transient reductions in strength. These could be appropriate responses to that type of loading. The answer to what's appropriate it depends on the load that you're giving, and there'll be a bandwidth of what's normal, right? So if you do see a reduction in strength or you do see a reduction in range of motion, then it's important not to not to panic on the back of that. That's some of those responses could be normal and with a given time course of recovery, it could be short, a short time course for very low stress throwing, or it could be a longer time course for higher stress throwing, your athlete might bounce back. And that that could be all normal to see it, see reductions in those things, to see a negative response, but it could bounce back within an appropriate time frame of recovery.

SPEAKER_01 5:12

I suppose that gives us a nice strong framework for what appropriate adaptation might look like. And then over to you, Mike, when you zoom in at a clinical level and in that throwing environment, clinically, what patterns

Adaptations to Increased Workload in Athletes

SPEAKER_01 5:24

do you see in how pitchers adapt or perhaps fail to adapt to those increased workloads?

SPEAKER_03 5:29

Yeah, good question. I think this, you know, piggybacks well off what Tim said too, is I think when you talk about load in a throwing athlete, it's a little different than some of the other sports that we may see, maybe in two potential ways. Let's compare maybe to like a hamstring strain and a field sport athlete, right? That's a muscle, a muscle tendinous junction. That's somebody working probably within the muscle tendons, normal loading capacity, that probably has some sort of workload spike, either too low, too little, and causes some issue. The problem what we have with our throwers is that when they throw, they essentially equal the failure of the tissue with each throw. So if you actually looked at the biomechanical studies of the stress that is absorbed, and we'll talk about the elbow, for example, because Tommy John injuries are just so popular in baseball now. If you were to actually look at the tensile strength of the UCL, the ulnar collateral ligament, your Tommy John ligament, and you actually look at that in a cadaver, the tensile strength is less than the stress that we see on each and every throw. And now, don't get me wrong, cadavers have very poor tissue quality, right? Right. So they're hard to base that completely off. But it's still close. But what happens is that we have the dynamic stabilizers, the muscles, the tissues around it that are the ones that need to protect it. So when we look at it in a baseball athlete, we're using structures, and structures are getting injured that are being used at complete end of their physical limits. And that's how our injuries occur. They're a little bit different. So, you know, we always start by saying, like, what are the normal adaptations? We say, well, the first thing we kind of teach you if you're an athlete and you're coming in at whether you're injured or you're trying to enhance your performance, we say the first step is you have to understand it's like throwing a baseball isn't good for you. It's actually a very stressful moment and it's it's a stressful activity to do. Now, we can build capacity to be able to absorb that as best we can, but it is very stressful and it surpasses the capacity of the body oftentimes. So once you understand that, it kind of makes sense. So the two things we tend to see with pitchers that are trying to adapt that training load is we say it very simply to them, you get tight and you get tired, right? So tired, obvious, it's easy. Your muscles get weak, the dynamic stabilizers get fatigued and they get weak from doing that. And then oftentimes it's why you'll have an injury to a static stabilizer like your UCL is because your dynamic stabilizer is fatigued out. But the other one is the tissue that we see the tightness of the decreases in range of motion, like Tim mentioned. And what we found through our research was that cumulative eccentric trauma. So if you look at the patterns and the motions that lose motion, it's from that cumulative eccentric trauma and have it. So you lose internal rotation. You actually lose a little bit of shoulder flexion, probably because of the lat and the teres major. You lose elbow uh extension because of the elbow flexors. If you really go through it, it's all the muscles that are working eccentrically. So what we do to monitor our barometer is how tight and how tired are those muscles that are absorbing the stress of each and every pitch. And that's how we try to keep track of them over the course of a season.

SPEAKER_01 8:29

Fantastic. So it sounds like there's an element of obviously there's heavy monitoring post-recovery. And I know, Tim, you mentioned it as well. What

Managing High Workload within Season/Competition

SPEAKER_01 8:38

sort of time frame do you gauge that over? Are you looking for some sort of tissue recovery over two days, seven days within the season and outside the season? How does it fluctuate?

SPEAKER_02 8:50

If you look at the way baseball teams will structure their workloads for their pitches, they generally work on a high low, high low model. Generally it's a five-day rotation. You might have some places that some teams allow a six-day rotation, but within that you have some high stress and low stress activity. So not every day is going to be hard throws, but it's important that in between starts, that there is some hard throwing to prepare the tissue for what's about to come in a game. Generally, though, if you work on that five-day rotation, then what that means is you're probably throwing hard, moderate to moderately hard every three days. On day one, you're in a game and you're on the mound, and then you'll have a recovery day on day two or lower stress day, and then you're starting to build in some harder throws somewhere between your first start and then your next start in in five days' time. And that pretty much sits within within the model of of what we'd recommend for lower body sports as well, that we're generally allowing 70 at least 72 hours between high stress days. If we think of something like the hamstring response to sprinting, if we sprint on Monday, generally we won't sprint again until Thursday. So 72 hours. But it it it may be that you allow longer between those high stress days. And again, it's gonna it's gonna depend on the tolerance of your athlete, right? So if you get to day three, 72 hours post, and that athlete's still sore or has reductions in strength, or has the tightness, so they're not moving well, or they're unable or unwilling to go into end ranges, then that might be an indication that they're not tolerating the load that you've just applied, that the light load is either too high or they need more recovery before they go back and do another high stress day. That's kind of a general online that we'd probably look for, but there might be some situations where athletes can adapt a little quicker. Maybe you could get some athletes out at 48 hours, but then maybe some will adapt a little slower and they they might need 96 or perhaps 120 hours to adapt to that high stress stimulus. So you've still got to think about you talk about it in in general terms, but you've still got to think about the individual athlete that you have in front of you.

SPEAKER_01 11:06

It's sounding like it reinforces that clinical interpretation. And as clinicians, it's obviously important to learn to read the signal and read the perception of fatigue and those performance shifts so that you can help support performance.

SPEAKER_02 11:20

I think in general, the research is great and kind of telling us how the average of a group will respond. In a lot of sense, when we're working with athletes, every athlete, it's an N of one. So we've got a we've got a framework to work towards that kind of guides our decision making. But then we still need to think about that athlete in front of us. And every athlete comes to us with different background, different story. And that could be injury history, it could be training history, it could be age, whether they're a young athlete or an older athlete, all of these kind of things feed into our the little algorithm in our head that's trying to manage that particular athlete as best as possible.

SPEAKER_01 11:58

Absolutely. Anything to add to that one, Mike?

Managing Baseball Athletes

SPEAKER_03 12:01

Yeah, I just, you know, I can't help but think, what just listening to Tim, that baseball is such an unfair sport where there's 162 games in 180 days. I don't think anybody else really does that, right? So you wonder why there's so many injuries, right? It's it's inevitable, it's bouncing, especially when we're pushing the envelopes with velocity now and pitch design, which just fatigues out the dynamic stabilizers. And it's just an unfair fight because to Tim's point, there's really no way to catch up once you get behind. Once your chronic workload gets super high, or once you even get super high with your Q chronic workload ratios, unfortunately, you need to pitch in four days. It's really hard to catch up. And trust me, we we've tried, right? We can minimize what we do in between starts if you start spiking too high. But inevitably, over time, it just becomes so hard because there's just so many games in such a short duration of time. It's a very unfair sport. I'll add that, I guess.

SPEAKER_01 12:56

Absolutely. Particularly when you're talking about that maximal tissue load.

SPEAKER_03 13:01

Yes, every time you throw.

SPEAKER_01 13:03

Yeah, that's huge. Let's use that now to explore building throwing capacity a little bit more. Tim, I'll throw it back to you. In your recent work looking at the relationships between training load, heart rate variability, perceptual fatigue, sleep, and injury and endurance athletes, you explored how multiple monitoring variables interact to reflect adaptation. So, how do you translate those insights into the throwing world? And specifically,

How to Differentiate Fatigue from Maladaptation

SPEAKER_01 13:30

how do you assess whether a throw is genuinely adapting to load versus beginning to accumulate fatigue or move towards maladaptation?

SPEAKER_02 13:39

Those measures that we had in terms of the response measures. So you mentioned heart rate variability and sleep and a few others in there, I I think they're probably pretty relevant to the endurance population. I'm not sure that I would use those particular measures for for a baseball player. If you go to Mike's point about playing 162 games in 180 days, it's not all the same field, right? So there's games that are on the road, they're back to back, so they'll play a game and then they're on a plane and they're going somewhere else. So sleep is going to be disrupted. When you're playing that frequently, I could almost guarantee you without measuring it, that heart rate variability, your sympathetic balance is going to be really high, your sympathetic tone is going to be really high. So me measuring that's probably not going to tell me anything other than what we probably assumed was the case anyway. And measuring sleep, sleep's going to be disrupted when you're moving around in different beds and different locations all the time. You're not going to have a consistent routine in terms of sleep-wake cycles. Monitoring arm health is critical, right? So what are some things that that we know might contribute to injury risk or performance when you combine spikes in training load or when you combine excessive training loads? And you can look at things like arm health, and different places are going to have different measures of arm health. If we look at the research around it, a lot of places are measuring some sort of measure of external rotator strength of the shoulders. So if external rotator strength starts to decrease, then that could be a sign of maladaptation. When your range of motion starts to decrease, that could be a sign. I know of some places who are just measuring a grip strength and they're using that as a measure of, well, it is strength decreasing, but what is a motor drive, what is neuromuscular drive? So they're kind of things that we can measure quite easily on a on a regular basis. And it becomes your screening actually becomes part of your response measure. So you've got your load measure. Not all pictures come with the same stress, but even if you just counted hard throws and that's that's your load measure, then you have a number of possibilities as your response measure that you could have going on a regular basis. So when the response variable tracks outside of a normal bandwidth or an acceptable bandwidth, then they act as little warning signs. You'll probably see the change happening over time. You'll see either strength decreasing over time or range of motion decreasing over time, and that they're your flags that that something has to happen here. You either have to manage the load a little bit better, or you have to manage the response to that load really well. You have to do it on the front end or you have to do it on the back end.

SPEAKER_00 16:32

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Managing Fatigue in Athletes

SPEAKER_01 16:58

That makes sense. So I suppose to clarify, you mentioned obviously tracking arm health and those variables. And we've also previously discussed that those changes might be an appropriate, acute change to load. So presumably in monitoring this, you're looking at that persistent change that doesn't recover over that 72-hour period.

SPEAKER_02 17:19

Yeah, and I th and I think what you're trying to do is think of arm health as almost like a rolling score. So it could be that you have a a three-day expected, you expect over three days that arm health is going to decrease. And you might have a picture in your mind of what normal looks like if you've got enough data, then you can start to map what normal looks like. So you can look at it in the short term, but you can also look at a rolling longer term arm health. So what is today's arm health compared to what it's been over the last for baseball? Maybe 15 games, or it might be 21 days, something like that. It could be 28 days if you wanted to keep it with a one-week and four-week kind of model. But the question you're trying to ask is where is my arm health today compared to when we're starting our pitching rotation? So when we're about to get on the mound when our arm health should be at its best, where is it today compared to then? And then where is it today compared to a longer period of time, say a 30-day window? Is it above or below or about average? And then you can start making some decisions. Now, of course, you're you've got data for that, but you've also got the player where you can just ask them a question. And they'll they'll be telling you, I'm sure Michael will tell you that he's worked with enough baseball players, they'll tell you when they're not feeling right.

SPEAKER_01 18:38

Everyone's got that pretty good internal sense.

Building Throwing Capacity in Pitchers

SPEAKER_01 18:41

And what about you, Mike? When you're building that throwing capacity day to day, what practical metrics or indicators do you rely on most when you're trying to build capacity in pitches?

SPEAKER_03 18:50

I'm pretty similar to Tim, and I'll start by sharing a quick story that I've told every now and then, but you know, it's kind of good. But when I interviewed for my first job in professional sports with the Boston Red Sox, which being from Boston, this is essentially my dream job, and I had an opportunity to interview for it. And I remember one of the questions that they asked me during the interview, they said, Mike, you've worked with a lot of injured baseball players in your career so far. How are you going to make the transition from working with injured players to healthy players? And I just, I don't know, I didn't think about this, I just blurted it out. I said, I think every time you pitch, you get injured, and I have five days to rehab you back. And they just sat back in their chairs and nodded. And I was like, oh, I think I just got the job. It was a good response, but that is how I consider it. And like I said before, you're at max capacity with throwing at all times. You get tight, you get tired. My job is to make you look like you every time you pick up a ball. So if the eccentric trauma of throwing yesterday caused some soft tissue tightness, some muscle tightness, whatever it may be, my job is to restore that tomorrow before you pick up a ball and play catch and to make sure that that is maintained and comes back by the time you need to compete again, right? Because everything that happens in between is preparing for competition again. So we we have to be careful of that. So, you know, there's two things we look at, right? We when we look at load and we look at acute chronics and chronic workloads, we usually use torque, right? So we just published a paper last year on the International Journal of Sports Physical Therapy of our interval throwing programs using torque-based biomechanical data to come with those very specific guidelines. So every throw at every distance has an amount of torque that is a certain percentage of max capacity of the Tommy John ligament, for example, your UCL. So we know we can build workload models based on that. That's how people get hurt, but I can't evaluate the UCL every day, right? Unless they're painful. And if they're painful, that's a whole different story. But to Tim's point, what we can see is we can see some of those barometers for of fatigue. We can see their range of motion loss. And for me, the number one barometer right now has been shoulder flexion. So shoulder flexion, range of motion. Everybody wants to talk about ERIR. Everybody thinks GERD's a problem. It's not. It's shoulder flexion, is the number one thing that we see. And then how it changes external rotation is probably why people get injured. I don't think GERD is a big contributor as much, that loss of internal rotation. It's the subsequent gain in external rotation that is probably the problem. And we know acutely and chronically you'll have changes in your range of motion that we just we have to play that game. We have to monitor them. We have to see are they gaining too much motion? Are they losing motion? Are they fatiguing? And we have to be careful with that. You said capacity and how we build capacity. And I'm going back between bit back and forth between two things, torque on a ligament, and then capacity of the muscles to be able to dynamically stabilize. It's two different things, right? One of the most important research articles that was published, I think, in the last decade on baseball players was by Peter Chalmers, came up with a study that essentially looked at ultrasound of the UCL at the beginning of a season, at the end of the season, and at the Start of the next season. And what they showed over the course of the summer was that the UCL got thicker and looser. And then over the course of the winter, the off season, it got tighter and smaller. And this may be the most important article because it tells us the keys to everything, but also the most misunderstood and misapplied article. A lot of people said the UCL gets thicker over the summer. And they thought hypertrophy, thicker is good. We need to throw more. The more throwing, the better. So that way a ligament hypertrophies. Ligaments don't act like muscles or bones. It's different. So we have to be careful with that. That larger ligament is swelling. That's interstitial damage that showed. So we showed for the first time that throwing damages the UCL, which we knew, but more importantly, that the off-season helps it recover, right? And unfortunately, a bunch of people said, oh, we need to not take time off from throwing so we can keep it bigger. I'm like, no, bigger is like swollen. It's injured. Like that's we want it to get tighter again. That's what we want. So it was the most misunderstood, but probably the most uh beneficial article I think we have because it showed that our off-seasons were very effective of controlling capacity. Everyone says about building capacity. It's really hard to build capacity in a ligament, but we can build capacity in the dynamic stabilizers to help protect that static stabilizer.

SPEAKER_01 23:18

That's a fantastic summary. And you're also clearly summarizing that sort of relevant knowledge of the literature, the knowledge of the loads that go through the elbow and upper limb, and that response to load is just crucial for clinicians. Let's cruise into balancing performance and injury

Motor Imagery Training for Overhead Athletes

SPEAKER_01 23:36

risk. Tim, you've done some recent work on motor imagery training as a load management solution for athletes. Can this relate to overhead athletes? And what would this look like practically for this population?

SPEAKER_02 23:49

Motor imagery is a it's an interesting one in that it's underutilized in sport, but potentially it could be used in a number of ways for both healthy and injured athletes or those that are rehabilitating. Now that the benefits of motor imagery is that it activates similar parts of the brain to actual motor activity. So if you were to throw a ball or imagine throwing a ball, you'll get similar activation in the brain. There's also some research that's shown, for example, in ACL patients, that you can get the same type of muscle activation, EMG activity, just through imagining doing the sport. So there's potential there to use it in terms of preventing muscle loss. There's the potential to use it to get mental reps as opposed to physical reps. So you you can you get if you've got an overloaded athlete, physically overloaded athlete, you can reduce the physical load but still maintain some sort of skill acquisition component to their training. So whether you have a an overloaded athlete, whether you have a healthy athlete and you just want to use it as a to to complement normal training, or whether you have an injured athlete who who can't do the same sort of physical reps, there's ways that you could go it in. Now I I don't know, no, if I would imagine actually that baseball players would probably be more inclined to do mental imagery than some of the other sports that I work with. I'm not too sure whether it's actually if there's any research that's shown that it's been used in baseball, but there's definitely applications there. I think the hardest part about it is probably convincing the coaches that you can get similar brain activity, you can get similar muscle activity just through sit thinking about doing exercise. Now it's it's not as simple as just going, well, I'm gonna think about throwing for a little bit. It depends a little bit on the skill of the performer. So generally what we find is if you're a highly skilled performer, then you're better able to generate appropriate images and you're you're better able to hold those images for longer. So if you haven't had experience with it, it's gonna take time to actually get good at it. It depends a little bit on what you're trying to achieve too, and whether you want to try and whether you use an external or an internal focus, so depending on the skill that you're trying to develop will depend on what focus you use. But it wouldn't be my first it wouldn't be my first go-to point to increase capacity. If I'm going to improve capacity of a tissue, or whether it be muscle, what or whether it be ligament, then my first portal call would not be I'm going to think about doing it. My my first portal would be, well, what are some physical things that we can impl implement, whether it be on the field or in the weight room to improve capacity, but it could definitely be used to complement complement training. I wouldn't see it as a replacement to training, but it could definitely be used to complement training.

SPEAKER_01 26:55

Sounds like a useful adjunct, which by the time you're reaching the professional level, it's those one percenters, isn't it? And I suppose it it broadens how we consider training beyond just physical throws as it relates to load. So,

Training Smarter and Harder for Throwing Athletes

SPEAKER_01 27:08

Mike, from a programming and clinical perspective, what does training smarter and harder actually look like in a modern throwing program?

SPEAKER_03 27:17

I was very eager to hear Tim's response to that question because I've been thinking about swinging my golf club like Tiger Woods for years, and it has not translated to my swing. I was hoping you could give me like a tip, Tim, that motor imagery would help me, but it sounds like it's just a small piece of that complex movement pattern.

SPEAKER_02 27:35

Give it a try, Mike. It won't hurt. It won't hurt you. That's fine.

SPEAKER_03 27:40

Sarah, I actually love your question and I love how you phrase it, training smarter and harder. The reason why I like smarter about that here is that I believe that education with our athletes is paramount right now. Most of these athletes have no idea what they're doing and what the impact of what they're doing is on their bodies. So we see lots of players, for example, doing things between starts or maybe in the off-season, all off season. They're long tossing, they're throwing max effort, weighted balls against walls all off-season, right? All these things. And what we try to teach them is that, like, what, you know, once you get to long toss to about 120 feet or so, the stress on the arm and the stress on the body is similar to throwing off the mountain. So it's very similar. Like your body doesn't care if you're pitching or if you're playing catch or if you're throwing a snowball at your little brother, or like it doesn't matter what you're doing, it just measures torque, right? And I think that's the important thing to kind of remember here. So, you know, 25 years ago, we finally started getting some injury data that was published. And the thing that we continue to show that correlates to injury more than anything else is overuse. And one of the big things in youth injuries that just blows your minds if you pitch for more than eight months out of the year, you are five times more likely to get hurt. That's enormous, 500% increase, right? If you pitch for more than eight months out of the year. So that actually worked for a little bit. That word got out there, the American Sports Medicine Institute and Dr. Andrews and Dr. Flight, they got this information out to the world that that existed. But then pitching coaches, athletes in the winter, they're still trying to get better. They start all these other training techniques with weighted balls and pull downs and long toss and extreme long toss to max distances, thinking that those throws are free, but they're not. The stress on those throws are equal to or even surpasses it. So you have people doing this all winter long. And I asked them, I said, Hey, would you throw a bullpen, would you throw off the mount three, four times a week all winter? And they'd say, no, no way. And I'd say, why not? They say, that's too stressful. And I'd say, Great, what you're doing is worse. Right. So the thing that you need to start with is education on what is stressful and how they stress that. And the athletes that I work with, it's a part of our process. We just, I slowly try to make them smarter, right? To your point, we train smarter and harder by understanding that. Because to me, that's how you handle that. If you have a high stress load in a game for whatever reason, pitch counts up, the intensity of your pitches were up. We have to cut back the next few days. We have to get that, you know, acute chronic to be able to settle back down and make sure that we're dealing with that. So those throws in between aren't free. They're part of the stress, right? And during the COVID, we actually did studies on this. We tried to look at all of our data with throwing pitches in a game, which is what people talk about, like innings pitched and pitches thrown per season. That's only about maybe a quarter of the amount of throws that they do all season. Right. So if that's the only metric we're going by where you get injured if you pitch more than X innings, that's the wrong metric. It's all the crazy stuff they're doing in between.

SPEAKER_01 30:41

That sounds like your most crucial point, isn't it? It's education on what load is, what stress is. And ultimately it sounds like that more is not more.

SPEAKER_03 30:52

Well, not when you're talking about stressing ligaments to their max capacity. Again, that's what throwing is a very different sport. It's different than a hamstring strain. It's different than other, you know, injuries you may have. It's just it's different. So it's education. And I'll I'll give the guys credit. Once you teach them, then most of the times they say, Oh, I didn't know that. And they say, Okay. And then they adapt and they have a great season, right? And that that that tends to be how it

Strategies to Manage Load Spikes in Athletes

SPEAKER_03 31:15

goes.

SPEAKER_01 31:15

Fantastic. That's a great answer, which probably segues nicely into this next bit, which is just exploring managing spikes and that real world variability. So I'll throw back to you, Tim. What strategies help prevent harmful load spikes in the unpredictable reality of a throwing season?

SPEAKER_02 31:36

Well, probably the best way to uh to avoid spikes is to raise your chronic load. And this is the challenge, right? Because if you start with zero, then anything above zero is going to be a spike. Or we use the 10% rule or the 10% guide, 10% of nothing is still nothing, but it's still going to be a spike depending on where you've come from. If you've come from the basement, then 10% could be quite a large increase. But the best way for you to manage spikes is to build your chronic load because it's much harder to spike training loads when your chronic load is higher than when it's lower. Now there's a challenge there though, and this is probably one of the differences between upper extremity sports and lower extremity sports, in that there's a fair bit of evidence to say that higher chronic loads have a lower risk that are associated with a lower risk of injury in lower body sports, but that's not necessarily the case in upper body sports. There's probably more evidence to say the opposite that if you have high chronic loads or excessive loads, and Mike used the hundred innings in a season, or that's what we see as a an excessive chronic load, when you have very high chronic loads like that, then that's that's going to increase your risk of injury in upper extremity sports. So there's a little bit of a difference between lower body and upper body sports. But in general, the easiest way that you can protect against spikes is to raise the floor. If you have a higher chronic load, if you build systematically and progressively to a higher chronic load, then that reduces your chance of experiencing spikes because it's harder to spike when your loads are already high. But your your tissues are better prepared for the load that's about to come. And even though we need to get away from the sport and we don't want to be throwing all year round, we want to maintain arm health in off-season, right? Off-season is not just a period of time where we say, all right, now we do four months of nothing and then go back and then start, oh, we're back in season now, so now we can start throwing hard again. You have to maintain arm health, and you can do that in a number of ways. It doesn't have to be hard throws all the time, but you might be doing some throwing during your off-season supported by what you do in the weight room. But then you have to go back and start all over again. Okay, just because I've done 10 seasons as a major league baseballer and I'm heading into spring training, that doesn't mean I can just pick up where I left off last season. I have to go through the process of building capacity and building in a sensible way. And building in a sensible way means progressively and gradually increasing load. It's not just about going, oh, this is where we need to get here, we're going to do it in one day. You need to kind of map it out, start with the end point, where do we want to get to, and then work your way back from that point.

SPEAKER_00 34:26

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SPEAKER_01 34:52

So just to clarify, that strategy of raising your chronic load, you're referencing that largely occurring in the off-season, knowing that there's high lows during.

SPEAKER_02 35:02

Well, I think you will be able to build chronic load in in spring training. I mean, that's part of why you have spring training. But realistically, once the season starts, if you haven't got the chronic load to begin with, or you haven't built a reasonable foundation or a reasonable chronic load, then there's no let up. Like when you're playing 162 games in a in 180 days, you can't play catch up there. Because if your chronic load is too low and then you start spiking loads on the back of that, you're asked to pitch a lot at high velocities, then that increases your risk of injury, which means ultimately your capacity is going to be driven to the basement again. So that means you've got to you can't you can't throw and you can't train as hard when your capacity is in the basement, which means your chronic load is going to drop again. So then you've got to go through that process of building chronic load again. You really only get one off season, you really only get one spring training. You've got to make the most of it, but you've got to do it in a sensible way. If you can't have a good off-season, which involves rest, but it also involves some training. If you can't have a good off-season, then it's highly likely that it's not going to set you up for a good spring training. And that means you're not going to be well set up for a good season. Conversely, if you have a good off-season, it sets you up for a good spring training, which then sets you up for a better season.

SPEAKER_01 36:26

Fantastic. Mike, when schedules and innings and recovery fluctuates, what about you? How do you manage workload when all of these things are in flux?

SPEAKER_03 36:38

I'll just I'll add to Tim's comment a little bit first, too. I think the nature of pitchers and the state of baseball right now, pitchers, I think, understand that. And if anything, they're probably building up to too high of a chronic workload before they start the season now. They're doing too much in the offseason, right? Which kind of comes to bite them later in the season. Or we actually see that, Tim, more than anything else, it's the position players that oftentimes come in and they haven't done anything, and then they just pick up a ball and start throwing. Sure, they're hitting, but they don't emphasize throwing enough. And then they wonder why all of a sudden they have to do 100 ground balls in a day and their elbow sore, right? So, you know, it's funny. You actually see that. Like the pitchers, I think, get it, but the position players, you know, it it happens a little bit more. To answer your question, though, Sarah, about like the real world of like how we manage that. What we have to be careful, right? We're talking about professional sports. And even if we're talking for if we're not we're talking about college, even high school, their goal is to get to the professional level. That's why they're doing these things. But what when you get to the professional level, they get paid to throw every five or six or seven days. They get paid. And some of them get paid between half a million dollars and a million dollars every time they pitch. Not just like for the year, every time. So if you really think about that, if there are innings and there's there's there are spikes, there, everything's going up in the game. Again, I have five days to get them back because the owner of my team is going to pay them a million dollars to get back on the mound in five days, right? So they need to get back on the mound in five days. And that's some of the sometimes the challenge. So if they're spiking their workloads and things are fluctuating, it's everything we need to do in between to be able to handle that. And, you know, second half of the season, the guys are skipping bullpens between starts, or, you know, they're just playing light catch for a little bit because their their spikes are so high. But remember, the high workload days are every five days. So when you're starting to see the light at the end of the tunnel and it's been six, seven months, and you got six weeks left, you start to manage it differently. You start to just play light catch for a few days instead of trying to manage it. And then you just give it everything you got on that fifth day because you owe it to your teammates, you owe it to the ownership group, you owe it to the fan base of that city, and that's what their motivation is. So it is a little different and it's all centered around that main competition day.

SPEAKER_01 38:56

That's a great summary. And now I'm curious

Key Takeaways

SPEAKER_01 39:00

before we wrap up, I'd love to hear both of your thoughts on some advice and perhaps some key takeaways from today's discussion that you'd give to the clinician listening, perhaps managing a throwing athlete. Tim, perhaps you first.

SPEAKER_02 39:18

You don't have to do it quickly. So get there as safely as possible. The third part would be monitor the response to throwing. So think about things that are that potentially could increase the risk of injury. So whether it's decreased strength or decreased range of motion and build that into your monitoring so that you're systematically building loads through either throw counts or something similar, hard throw counts, and then monitoring the response to that. Think about a timeline of recovery, think about what is a normal bandwidth of responses, and that's probably the safest way that we've got to build capacity is load and then monitor the response to that load. There's two ways that you can improve capacity that I'm aware of. One is that you do it on the front end through training load, and that's through progressively just throwing a little bit more to a point. The second way that you can do it is manage it on the back end, and that is by managing the response and the health of that athlete, and in this case, the arm health of the athlete. If you've got an athlete that's at high loads and you can't load anymore, I can almost guarantee you that athlete wants to improve capacity. If you can't do it through load, the only other option you've got is to manage the response and manage the arm health of your athlete. So you're just trying to prop that health up as much as possible so that capacity is maintained. So there are your two options: load and the health component or load and check the response before deciding whether to load again.

SPEAKER_01 40:50

Fantastic takeaways.

SPEAKER_03 40:51

That was such a good response. I would actually say just re-listen to what Tim just said would be my biggest takeaway because I think he nailed that. That was fantastic. But honestly, my biggest takeaway, I think in our profession, especially upper extremity sports and baseball, like I still think this workload monitoring and this concept of workloads is a little bit newer to us than some field sport athletes. So my biggest recommendation for somebody listening to this is to dig into Tim's work. I know when I did that several years ago, I'm a better clinician because of it, right? What Tim teaches and the constants of workload management and even the science behind workloads, it's a different way of thinking that I don't think the rehab professionals always think of. So when you start adapting the concept of workload and capacity to really everything we do throughout our entire profession, every injury, I do think it's a game changer for us. So, you know, dig through Tim's work. It's going to take you a year. He's got a lot of public publications, but I'm a better clinician since I learned from Tim and went to one of his courses, and it was fantastic. So I would do that. Read our paper on interval throwing programs, where we basically just took Tim's models and his work and applied it to the baseball throwing. So you can see how we applied it to baseball. And I think that's a really good place to start. I think I think that's made me a better clinician. I think it'll help everybody listening to this as well.

SPEAKER_01 42:11

That's a fantastic summary from the two of you. So we're systematically building to higher loads, we're monitoring the response to throwing, improving capacity front end through training, or managing it on the back end by managing response to training. Mike, we're reading your paper on interval throwing programs, and we're all going to read Tim's work. Well, thank you both so much for joining us today. I think there are so many practical takeaways for those clinicians that are managing throwing injuries and a really valuable discussion on load and how valuable education is as well. So thank you both.