Latest / The Layback Podcast / Forearm Flexor Strength Imbalance Correlation with UCL Injury in Baseball Athletes (Ep. 71)

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Forearm Flexor Strength Imbalance Correlation with UCL Injury in Baseball Athletes (Ep. 71) · The Layback Podcast

0:00
Hey, everyone, welcome back to the Lay Back podcast.
0:02
We have another different one for you today.
0:05
It's going to be another webinar recording.
0:07
Our featured presenters will be Toby Addis and Drew Hagen.
0:11
They're both entering their third year at the Edward Via
0:15
College of Osteopathic Medicine, the Blacksburg campus.
0:18
So they are at Virginia Tech currently.
0:20
They both have some really impressive backgrounds already
0:24
and I know they're going to do amazing things in the medical
0:26
field. Joining them we have again host
0:30
or moderator Dr. Matt Fury and on the panel today will be
0:34
Doctor Gunner Burlinson, Emily Ferree and Mike Mcferrin of the
0:38
Athletics. Today's topic is forum flexor
0:41
strength and balance and correlation with UCL injury in
0:45
baseball athletes. So obviously this becomes
0:48
extremely important for risk flagging and really just
0:52
assessing athletes to make sure that they are well equipped to
0:55
handle the stresses of throwing, whether that be one time or that
1:00
be for a season or even a career.
1:03
So before I butcher anything, I'm going to pass it off to
1:06
these guys over in the webinar. Hope you guys enjoy this one
1:09
today. If you have any questions
1:11
whatsoever, definitely let us know.
1:13
We'll have AQ and A that's going out to everyone who is in
1:17
attendance. So if you guys want to reach out
1:19
specifically and see what questions were asked, I'm sure
1:23
we can find a way to get that to you guys as well.
1:25
So until next time, thanks for laying back with us.
1:29
All right. Well, look, it is 11 O1.
1:31
I want to be respectful of everybody's time.
1:32
We got a lot of folks are still piling in right now.
1:35
And so as they join, hopefully we'll just get everybody up to
1:38
speed. So thanks again.
1:41
Welcome back for everybody who's coming back after our last
1:44
session. Thanks for for all who are newly
1:47
joining us just to to revisit this.
1:49
We're here for really one purpose.
1:51
We're here to try and do whatever we can do to share
1:54
knowledge, to ask questions, develop new questions, really
1:58
brainstorm. This exchange is really helpful
2:01
for me personally. It's helpful for a lot of us to
2:03
reevaluate what we believe, right, to see if we know what we
2:06
think we know and really ask the next question.
2:08
So we can do what we can do to minimize risk, reduce these
2:12
injury rates, while also support our athletes who who are seeking
2:15
performance. And so that's why we're here.
2:17
A couple of housekeeping notes. This Zoom call is going to last
2:21
an hour, certainly not more than an hour.
2:23
If we wrap up sooner, then we'll, we'll wrap it up.
2:25
We're going to be respectful of everybody's time.
2:27
You can see that there is a chat function.
2:30
So we don't have the Q&A function like we had last time.
2:32
So this is going to be a little more helpful to keep on top of
2:35
the questions. But as you hear the presentation
2:37
say, as you hear the discussion, please put some questions into
2:40
the chat. This should be interactive.
2:42
We're hoping to, to bounce things off each other and to, to
2:45
learn and, and pick the brains of our panelists here.
2:48
Anything that we can't get to, just like last time, we're going
2:50
to collect. We're going to get together as a
2:52
panel. We'll answer any of the
2:54
unanswered questions and then we'll recirculate to everybody
2:57
who RSVP D for, for this webinar.
2:59
This will be recorded. We'll let you know how we're
3:02
going to act. You know how you can access this
3:04
and, and, and rewatch it. And yeah, with that being said,
3:07
it's 1103. Let's get started.
3:08
So my name is Matt Fury. I'm an orthopedic surgeon.
3:12
I'm in Baton Rouge, LA. I am a shorter elbow sports
3:16
medicine surgeon with a passion with taking care of baseball
3:19
athletes. I did my training at Harvard for
3:21
residency and at HSS for fellowship where I was one of
3:23
the assistant team docs with the with the Mets helping take care
3:26
of them when I was up there and then now I'm down in Baton
3:29
Rouge, LA. I'm a team position for LSU and
3:32
passionate researcher for shorter elbow and baseball
3:35
sports medicine injuries. Enough about me.
3:38
The panelists today we're joined with a great group.
3:40
So first up, Gunner Bowlinson, who is joining us, I believe by
3:44
phone but should be here just shortly.
3:46
Gunner is a vice president for research, professor of family in
3:49
sports medicine, the Edward Via College of Osteopathic Medicine.
3:52
He's the director emeritus of the primary care sports medicine
3:55
fellowship there at V com and at Virginia Tech.
3:58
He's a former head team physician for Virginia Tech,
4:00
past president of the American Osteopathic Academy of Sports
4:03
Medicine, member Olympic Sports Medicine Society, and a
4:07
researcher and somebody who shares a lot of the same
4:09
passions. So Gunner, anything else to add?
4:12
I don't know if you can hear us yet.
4:13
Not quite. He'll be joining us just
4:14
shortly. So that brings up to our second,
4:16
our second panelists. Emily Free.
4:18
Emily is a physical therapist. She's the founder of the Free PT
4:23
Lab. She's got ton of experience with
4:24
professional athletes from multiple sports, NFL, MLB, NBA,
4:29
MLS, NHL, really kind of covering it all.
4:31
She's a certified manual therapist and really a bio
4:33
mechanics movement expert. Emily, could you tell us a
4:37
little bit more about your, your passion, sort of what got you
4:39
here And yeah, share a little bit more anything I missed?
4:43
Yeah, my passion in in terms of physical therapy really started
4:47
with bio mechanics and analyzing bio mechanics and in particular
4:51
3D sports. So looking at things like
4:53
pitching, overhead volleyball, swings, stuff like that.
4:56
And so I really kind of grew a passion for throwing and
4:59
pitching specifically and kind of flew myself around the world
5:03
to learn bio mechanics because it's in particular with pitching
5:06
because because it wasn't something that came typically
5:08
with school with PTS. And then started working with
5:11
some teams and some baseball performance individuals.
5:14
And we built out a baseball performance lab and have been
5:16
setting pitching bio mechanics ever since.
5:19
Great. Well, thanks for your passion,
5:21
all the work that you're doing that.
5:22
That brings us to the next panelist, Mike Mcferrin.
5:25
He is the pitching coordinator for the A's pitching lab
5:29
coordinator and the player in the development of player
5:31
development at Wake 4 previously from 2021 to 23.
5:36
Really, you know, he's on the forefront the science data
5:39
technology to improve baseball pitching performance.
5:40
He he was one of the creators of the the Wake Forest Bridge
5:44
seminar, which over the past couple years has just continued
5:46
to grow and been a great exchange for some of the
5:48
brightest minds around baseball. Mike, anything else you want to
5:51
add or tell us a little more about your your story and
5:53
background? No, yeah, I'm happy to to be
5:56
here. I've known Daryl and and Adam
5:57
for quite a while and, and their work, I think it's
6:00
revolutionary. I'm trying to stop these
6:03
injuries from happening in the elbow.
6:04
And I think it's, you know, something that is really pushing
6:07
the foreground, like you said, of, of how to keep elbow safe.
6:10
And it goes hand in hand with player development, which is
6:12
very cool. So hopefully I can add something
6:14
from the on field side of things and in addition to the pH DS
6:18
that I'm surrounded by here, which of course don't have, but
6:21
happy to be here and hopefully can add some value.
6:25
Great. Thanks, Mike and it brings us to
6:27
our presenters for today. So Toby Addison and Drew Hagen,
6:31
both Toby Andrew or third year Med students over at the Edward
6:34
Via College of Osteopathic Medicine, Toby's the 2027 class
6:38
president. He's got a master's in public
6:39
health and a master's in biomedical sciences.
6:42
And then Drew, he's got a bachelors of science in
6:45
biomedical engineering was Magna cumulate of his graduating
6:48
class. Toby, Drew, do you want to share
6:50
a little bit more about your background before we we load up
6:53
the presentation and and get going?
6:55
Yeah, absolutely. Thank you, Doctor Perry.
6:58
Yeah, I think most of my sports background really actually
7:00
doesn't come from the pitching world.
7:02
My sports medicine background actually comes from snow sports.
7:06
So I've worked as a national ski patrol, Alpine ski patroller for
7:09
several years, a mountain travel and rescue instructor and also
7:14
an EMS sphere. Of course, plenty of traumatic
7:16
injury there. But I'm really excited to step
7:19
into the world of sports medicine and the pitching
7:21
sphere. And it's been really interesting
7:23
thus far and I'm really excited to keep moving in the in the
7:25
sector. Awesome.
7:27
What about you, Joe? Yeah, not as much experience as
7:30
Toby in the room, but through going to V Com, through Doctor
7:33
Brolinson, as well as some of the current team positions
7:35
there, have been fortunate enough to be on the sideline for
7:38
many of the Virginia Tech sports teams.
7:40
Learn a lot about where it goes and how it works day-to-day and
7:44
stuff. And it's really inspired me with
7:45
a lot about sports medicine. And I think it's really cool to
7:48
be able to conduct research and learn more about it to help, you
7:51
know, find some answers and hopefully provide some solutions
7:54
into the future. Perfect.
7:56
Well, look, why don't you guys load up, start screen sharing,
7:59
load up your presentation. Toby and Drew are going to give
8:02
us a presentation today on a study that they've been doing
8:04
looking at form, flexor strength and the association with UCL
8:09
injury. So Toby, Drew, take it away.
8:12
We'll move through your presentation and then after
8:14
we're done, we're going to open it up to the panel.
8:17
Awesome. Thank you so much, Doctor Fury.
8:19
Yeah, Thank you to everybody that can make it here today.
8:21
Good afternoon. Drew and I will actually be
8:24
talking about a little bit of research we working with with
8:26
Doctor Pirie, Dr. Burlinson, many others.
8:29
And what we've been doing is exploring the correlation of
8:32
forearm flexor strength and imbalance with UCL injury risk.
8:37
So we've already talked a little bit about ourselves.
8:40
So we don't want to go load of ourselves too much.
8:42
But like Doctor Fury said, Andrew are both third year
8:45
medical students at the Edward Vibe College of Osteopathic
8:47
Medicine. My background comes from
8:50
starting off in UVA with ABA in biology and then a Master of
8:54
Public Health at the University of Virginia School of Medicine
8:56
and then moving over to BCOM for Biomedical Sciences masters.
9:01
And here we are now, Med student, trudging along.
9:04
Yeah, that's awesome. And I'm really happy to be here
9:07
for everyone who's able to make it.
9:08
And yeah, I completed my undergrad at Virginia Tech and I
9:11
was fortunate to stay in Blacksburg to stay at V Comm and
9:14
continue this journey there today.
9:15
And so here's just a quick objective.
9:17
So we're going to talk about muscle imbalance first, as well
9:19
as some anatomical relationships of the UCL.
9:22
And then I'm going to hand it back over to Toby or he'll give
9:24
us an overview of our study titled Neuromusclear Imbalance
9:27
in UCL Injury. We'll have a brief discussion
9:30
and some conclusions and then we'll open it up for some
9:32
questions. OK.
9:33
So to begin we will talk about what is muscle imbalance.
9:36
So muscle imbalance can be defined as muscles being unable
9:39
to properly performed due to being over lengthened and
9:42
weakened over shortened or fatigued from over activity.
9:45
And some examples listed here include left versus right
9:47
muscles, anterior, posterior and flexor versus extensor.
9:51
Of course, we would expect certain athletes to have
9:53
inherent muscle imbalances and left versus right limbs due to
9:56
dominant sides or even due to the nature of the sport playing
9:59
position, such as pitchers having a stronger pitching arm.
10:02
But when we look into muscle imbalances and how they impact
10:04
UCL loads, we look at different muscle groups within the same
10:07
limb that work synergistically with each other to perform a
10:10
specific movement, such as the Forum Flexor muscle group.
10:12
So muscle imbalance can have significant impacts on baseball
10:14
athletes, especially in pitchers.
10:16
Athletic performance in baseball is a common source of muscle
10:18
imbalance. Due to the repetitive, sport
10:20
specific movements, they often favor certain muscle groups over
10:23
others. When athletes consistently train
10:26
or compete without equally strengthening synergistic
10:28
muscles or their opposing counterparts, imbalances can
10:31
develop. These imbalances not only limit
10:33
range of motion, strength, and movement control, but they also
10:36
increase the risk of injury as the body compensates by placing
10:40
undue stress on associated joints, tendons, and ligaments.
10:44
Overtime, these issues can hinder performance, delay
10:46
recovery, and potentially even shorten an athlete's career.
10:50
So the forearm flexor muscle group provides important
10:52
protective effects to the owner collateral ligament, or UCL,
10:55
especially when performing repetitive throwing motions.
10:58
The group includes the flusher dorm superficialis, the flexor
11:01
digitorm profundus, and the flexor carparello ulnaris, each
11:05
of which can be visualized on the image on the left side of
11:07
the screen. These muscles are found on the
11:09
medial side of the forearm and feature an origin in close
11:12
proximity to the UCL, which can be visualized on the image of
11:14
the right. Studies have shown that these
11:17
muscles can compensate the large external valgus torque
11:19
experienced by the medial elbow during pitching through dynamic
11:22
stabilization of the forces across the medial elbow, which
11:26
helps reduce strain on the UCL and absorb or distribute valgus
11:29
loads that would otherwise be transmitted directly to the
11:32
ligament itself. So, in order to confirm these
11:35
anatomical associations at a fore muscle tendons at the UCL,
11:40
fine wire electromyography or EMG study was conducted at the V
11:44
com Virginia campus. The results of the study
11:47
confirmed the anatomical association of the form flexors
11:50
with the UCL through demonstrations of flexor
11:53
digitormum superficialis targeting during mid finger
11:55
flexion and flexor carpi owneris targeting during ulnar
11:59
deviation. Furthermore, it was also
12:01
demonstrated that a flexion force from distal attachment
12:04
applied roughly 60% more stress to the flexor digitorm profundus
12:08
than the flexor determ superficialis.
12:10
So with that, this leads us to believe that although despite
12:13
really being studied, the flexor dorm profundis may also play a
12:16
vital role in protecting against distal UCL tears.
12:19
And so the findings from the study confirm the antimico
12:23
association of the previously of the three previously listed form
12:27
flexor muscle tendons at the UCL and progressed us to our
12:31
research project. All right, so now we want to
12:34
dive into what we did together with Doctor Brawlinson, Dr.
12:37
Perry, which was our retrospective cohort study on
12:40
neuromuscular imbalance and UCL injury.
12:44
So we felt that it really was important to focus in on
12:46
neuromuscular imbalance specifically.
12:48
And there is previous research, for example, a study out of the
12:52
University of Florida that found that 52% of patients with the
12:56
UCL injury also had a forearm flexor injury.
13:00
There really was a substantial lack of research that examined
13:04
the potential contribution of muscle strength and balance
13:07
towards the mechanism of medial elbow injury in pitchers.
13:10
So that's what we aimed to look at.
13:13
So as far as study design goes, this was the overarching
13:17
methodology we can see here that we developed to explore the
13:20
research question of how that muscular imbalance in the
13:22
forearm flexors was correlated to UCL injury.
13:26
So now we can go in and dive into each portion of the methods
13:29
here and see how it all shook out.
13:31
So we start off with our data collection.
13:33
Data on flexion strength was collected using the Flex program
13:37
device, which was uniquely suited for this application
13:40
simply because it has the ability to isolate fingertip
13:43
flexion strength and mid finger flexion strength.
13:46
And this is done by adjusting the finger receivers on the Flex
13:49
Program device and they can either engage the distal
13:52
phalanges or the middle phalanges.
13:54
And then the subject would be instructed to flex 90°, the
13:59
shoulder and the 90° of the elbow.
14:01
And that can be seen in the image here on the right under
14:05
the supervision of a trainer. The participants of our study
14:08
were instructed to perform a one Rep Max isometric flexion of
14:13
fingers 2 through 5 for a total of 3 seconds.
14:16
And then the device would automatically record the highest
14:19
force input received at any given point within that 3 second
14:23
frame. And that was basically what was
14:26
the study measure that we were recording.
14:29
So after we did that with all the subjects and collect all the
14:31
data, we could actually take a look at what we collected here.
14:34
So the left side chart would actually be our injured cohort
14:37
and our uninjured cohort is here on the right.
14:40
So after we collected that data from the subjects, we also
14:42
collected a history from them about upper extremity injuries.
14:47
And if they met the criteria in our study, which was medial
14:50
elbow injury within three years of the reading, they were
14:53
included into the injured cohort.
14:56
Now the data points that we specifically collected from each
14:59
of these participants was a four finger fingertip flexion
15:03
strength, 4 finger mid finger flexion strength.
15:06
And then we also calculated the mid finger over fingertip
15:09
flexion ratio for the injured cohort, specifically the types
15:13
of injuries that we saw in the study.
15:15
They can be seen here in this right column of the left table.
15:19
They included brains, strains, pain, tears, and repairs of the
15:24
UCL or associated flexors. And pictures that had no such
15:28
history of injury were recorded in the uninjured cohort here on
15:32
the right. So once we collected all of that
15:34
data, we performed 2 sample T tests.
15:38
After verifying the test assumptions.
15:40
We did that utilizing our studio for all of our statistical tests
15:44
and the assumptions of normality and equal variances were
15:47
verified using the 2 sample F test and the Shapiro Wilkes test
15:51
respectively. We then also performed A2 sample
15:54
Man Whitney U test simply for robustness.
15:56
But what we found was actually that the T test and the Man
15:59
Whitney U test or the will cost and rank some test found
16:03
statistically significant P values for the four finger
16:06
fingertip flexion strength, the four finger mid finger flexion
16:09
strength, and then the ratio of mid finger over fingertips
16:13
strength. And you can actually see the
16:15
outputs of the R algorithm here on the bottom for those three
16:18
tests statistics. So what did the results look
16:21
like? So here we can actually see the
16:23
P values for each of the groups from the 2 sample T test, which
16:27
showed a point O3 for the fingertip flexion strength and
16:31
then for both the mid finger flexion and the mid finger over
16:34
fingertip flexion ratio, the P value is actually less than
16:37
1000. This table here at the bottom
16:40
actually shows the output for our cut point analysis.
16:45
The cut point analysis essentially looks at the
16:48
different cut points that we could theoretically use for
16:52
using this test as a like diagnostic or predictor.
16:56
So this is essentially an output of sensitivity and specificity
16:59
for the test and how that changes if we change the ratio
17:03
cut points here on the left. So a.
17:06
Little bit about what we found our findings.
17:09
Like we said, our P values are extremely significant.
17:12
The results of the statistical analysis actually suggests that
17:16
there was a measurable correlation between mid finger
17:19
and fingertip flexion strength with pitching associated
17:22
injuries in baseball pitchers. An underlying mechanism when we
17:26
were diving into literature about this that could explain
17:28
this phenomenon is that the relatively lower mid finger
17:31
flexion strength in the injured cohort indicates that the flexor
17:35
digitorum superficialis is actually unable to provide as
17:39
much muscular support to the humor ulnar joint and therefore
17:43
that would dispose the ulnar collateral ligament or UCL to
17:46
experiencing higher stresses. The fingertip flexion strength
17:49
discrepancies between the injured and uninjured cohorts
17:52
indicate that the flexor reduced harm for fundus was also lacking
17:56
in providing that protection against digital UCL tears.
17:59
When we also looked at the lecture, we found that this
18:01
mechanism was corroborated by findings from actually research
18:05
out of Japan by Queso and their colleagues that found that 89%
18:09
of the participants in their study with combined UCL and
18:13
flexor pronator muscle injury had identifiable injury to the
18:16
flexor digit towards your fiscalis.
18:18
So when we actually go down here to this table, again it's the
18:22
same table as seen in previous slide.
18:23
We see that if we utilize the mid finger over fingertip ratio
18:28
as a predictor of medial elbow injury, there is actually a very
18:32
promising utility of this tool at the .89 cut point.
18:38
So we figured that the .89 cut point out of the analysis
18:42
yielded the highest utility and that's because the sensitivity
18:45
there was at 100% or 32 out of 32 for our sample.
18:49
And then the specificity was also exceedingly high at 92.86%.
18:54
And that provided the best combination of utility and use
18:58
for this test as a predictor or a diagnostic.
19:02
So when we look at grip strength dynamometry versus isolated
19:07
flexor dynamometry and we found that there was a significant
19:10
importance to what we were doing in our research.
19:12
Silly because grip strength testing, which has been widely
19:15
adopted in professional baseball as a practical measure of local
19:19
muscle function relative to elbow stability has existed for
19:22
a long time right? And has a very high test retest
19:25
reliability in populations musculoskeletal conditions.
19:29
But it primarily measures combined force output of
19:33
multiple forearm and hand muscles.
19:35
And that really shows that there's a lack of
19:37
distinguishment with the contribution of individual
19:40
muscle groups. So in a clinical context, that's
19:42
really important because where there might be specific muscle
19:45
imbalances present, overall grip strength may remain within
19:49
normal limits and they might mask the deficits that key
19:52
stabilizing muscles that are relevant to injury risk, right?
19:56
So by having that combined force, you could have
19:58
compensation that provides A masking effect.
20:01
Whereas with isolated flexor dynamometry, we have the ability
20:04
to actually look at specific flexor groups and measure those
20:07
imbalances, and we believe that finding those muscle imbalances
20:10
can significantly undermine the reliability of group strength
20:12
measurements. All right.
20:15
So now like looking at our results versus hand grip
20:17
dynamometry, I think Toby did a really nice point by talking
20:20
about how like through our research and such, we found that
20:22
muscle imbalance can significantly undermine the
20:24
reliability of grip strength measurements.
20:26
And in a July 2024 study titled Is there a Relationship between
20:30
Grip Strength and injuries and professional Baseball players,
20:33
which involves, I think, 213 Pitchers?
20:36
Researchers concluded there was no significant difference in
20:38
mean grip strength or changing grip strength as measured by a
20:41
hand grip dynamometer over the course of a single baseball
20:44
season between pitchers who sustained a shoulder or elbow
20:47
injury and those who did not. And this was likely due to the
20:49
fact that the strength measured by the hang of dynamometer is
20:51
based, as Toby said, on the combination of the strength of
20:54
the FDS and the opposing strength of the palm and thumb,
20:57
with the palm and thumb having really no real role in
21:00
protecting the ONOR collateral ligament.
21:02
And additionally, when measuring strength in the handheld
21:04
dynamometer, users are in a nearly closed fist position,
21:08
which places the FDS at its near end range of motion, creating a
21:11
distorted length tension effect that is markedly different from
21:14
what a pitcher actually experiences at Max layback when
21:17
torque on the medial elbow UCL is at its peak.
21:22
And so why was flexible grip optimal for our study?
21:24
So to begin, the flexor dorm superficialis and flexor dormer
21:27
frontis muscle tendon units are very difficult to isolate and
21:30
target. And like we mentioned, the
21:31
flexible grip device can perform isolated dynamometry.
21:35
But also importantly to us, it has the benefit of measuring the
21:37
flexors at their long muscle length, like completely
21:41
outstretched, rather than their shortened length as hand grip
21:44
dynamometers do. While measuring flexion was the
21:46
most important considerations for our study, the flexor group
21:48
also has the capability to measure extensor and risk
21:51
deviation. Those features combined with the
21:53
ability to objectively quantify load from specific muscles made
21:56
at the ideal device for our project.
21:58
And so the question remains whether form flexor weakness
22:00
precedes injury or whether injury can leads to form muscle
22:05
weakness. The nature of the retrospective
22:07
cohort study does not help address the specific issue.
22:10
But while it's certainly possible, the high correlation
22:12
between those who had relatively weak flexure dorm superficialis
22:15
strength and prior UCL injury leads us to believe that there
22:18
is currently no good reason to not proactively have any pitcher
22:22
with flexure dorm superficialis strength training to boost their
22:26
FDS strength and or stiffness. Especially when you couple this
22:30
with Jessica Geiger's recent Wake Forest study, which found
22:33
that pitchers who trained on flexible grid for 10 weeks
22:35
experienced a 43% decreased in medial elbow gapping.
22:39
Additionally, several other research studies have found that
22:41
roughly 50% of the time a pitcher tears his UCL, he also
22:45
suffers A flexor tear, and 90% of the time this involves the
22:47
flexor storm superficialis. So it seems rather obvious that
22:50
a weak flexor digitorum superficialis puts both that
22:54
muscle and the UCL at risk of injury.
22:57
All right, So what do we conclude from these statistical
23:00
findings? Well, to concatenate those
23:03
findings, the results from our statistical analysis simply
23:06
demonstrated A measurable correlation between mid finger
23:09
and fingertip flexion strength and throwing associated injuries
23:12
in pitchers, specifically UCL injury.
23:16
So it's important to mention that there were some limitations
23:18
of the study that we encountered that included having a
23:21
relatively smaller sample size. We had an end of 74 and it only
23:25
included pitchers, right? The heterogeneity of injuries
23:29
experienced by that injured cohort was relatively wide.
23:32
Of course, we limited our inclusion criteria to
23:35
specifically include injuries that are relevant to use to the
23:39
UCL Humor Owner unit, but having higher precision on injury types
23:43
could possibly help pinpoint findings on which types of
23:46
injuries are most positive. So with that in mind, we think
23:49
that future work should focus on increasing those sample sizes,
23:54
including research on other myo tendonus units crossing the
23:57
humoral on or joint, for example, the flexor
24:00
carpiulinaris amongst others. And perspective research on UCL
24:03
injuries following flexor strength measurement could help
24:07
distinguish that temporal relationship that Drew was
24:09
talking about between weakness and injury or injury and
24:14
weakness. So what are our thoughts?
24:17
So Simply put, the diagnostic and predictive benefit of this
24:22
device and also measuring forearm flexor weakness seems to
24:26
have a really promising Ave. at this current junction.
24:29
Without perspective research on the predictive value of these
24:32
measurements, the device can either be used as a diagnostic
24:35
of injury. And that would happen if the
24:38
case was that injury precedes weakness or if weakness precedes
24:42
injury, this could really be used as a predictor, right.
24:46
So regardless, the specificity and the sensitivity of the test
24:51
as demonstrated by that cut point analysis is exceedingly
24:54
strong. And because of that, we think
24:56
that there is significant utility in either regard if you
24:59
want to use it as a predictive device or a diagnostic device.
25:03
So in the case of strength training, our findings suggest a
25:07
nearly irrefutable benefit to focusing on forearm flexor
25:11
training in order to strengthen that humor ulnar musculoskeletal
25:14
structure. Utilizing isolated flexor
25:16
dynamometry to track strength progression and then utilizing
25:20
that data to focus on reducing imbalances should really provide
25:24
protective benefit to pitching athletes.
25:26
We hope that future research will help to confirm that
25:29
temporal relationship of weakness to injury or injury to
25:31
weakness. But at this current junction
25:33
with what we know, strengthening the FDS and the FDP should
25:37
really be a priority to help reduce the prevalence of UCL
25:40
injury in baseball pitchers. Yeah.
25:43
And just to add to that, I think Toby said it beautifully.
25:45
I completely agree. But really I believe that no
25:48
matter which way you think of it, form flexor muscle imbalance
25:50
and Ucilla injury are intertwined and highly
25:52
correlated. And regular targeted
25:54
strengthening of the form flexor muscle group ensures these
25:57
muscles are prepared to provide protective support before issues
26:00
arise, making them an important preventative strategy for all
26:03
pitchers aiming to avoid UCL injuries.
26:05
Importantly, strengthen the forearm flexor muscles is low
26:09
risk and targets the natural stabilizing capability of the
26:12
forearm on the UCL. And unlike some other
26:16
potentially like high intensity or complex training protocols
26:19
that can strain joints or compromise them, these targeted
26:21
movements build functional muscle to aid in injury
26:24
prevention and improve performance, making them
26:26
suitable for athletes at any level without really introducing
26:29
any new risks. And before we wrap up, we just
26:32
wanted to have a couple of acknowledgements.
26:33
We would like to express our sincere gratitude to everyone
26:36
who played a vital role to this research project throughout its
26:38
development, including Doctor Burlinson, Dr. Redden, Doctor
26:42
from Eric, Doctor Rogers, Doctor Kozar and of course, Dr. Fury.
26:47
Drew, Toby, thank, thank you so much for taking the time here
26:50
for a great presentation, for sharing everything that you guys
26:53
have been working on. Just some quick thoughts for me
26:55
and then we're going to bring to the panel and pick the expertise
26:58
of of our great panelists here. You know, I think one important
27:02
thing to highlight is, is like you said, this is a
27:04
retrospective study that determined association, right?
27:09
And so in the retrospective study, we we found that there
27:12
was an association between FDS weakness and UCL injury and and
27:18
that ratio of FDS to FDP, right? And so the next step here, the
27:23
next step here is really a perspective study to where you
27:26
have from the outset, you have throwers who are either either
27:29
FDS FTP balanced or FDS FTP unbalanced.
27:32
And then we follow them longitudinally, right?
27:34
And so that's the best way to do good science and take that next
27:37
step. But to your point, Drew, kind of
27:39
when you're when you're wrapping things up, it's hard to to
27:43
necessarily sit on the sidelines with the data that we have now
27:46
and not do anything. And so for me personally,
27:48
clinically in my throwers, I'm using strength benchmarks for
27:52
both the FDS FTP and the ratio of FDS FTP strength in my return
27:55
to throw determinations like my objective testing battery and in
27:59
my post operative protocols too as well.
28:01
Because I think we saw from Jessica Geiger's work and what
28:04
she presented last time we did this about how this is
28:07
trainable, right? And we see a measurable
28:10
difference in joint space gap, right, with a training
28:13
intervention. And so for me, I think it's low
28:15
hanging fruit to attack, you know, from this, from the the
28:19
surgeon patient counseling side of things.
28:21
But the next step though, for good science would be doing a
28:23
prospective study, which is what we're going to try and do here.
28:26
Thanks. Thanks again.
28:27
I'd like to get Mike and Emily, I don't know if Gunner has
28:30
gotten to a spot where he can chime in quite yet, but but
28:33
Mike, let me call on you first. Initial thoughts just after
28:38
hearing Toby and Drew. What are your what are your big
28:40
takeaways from this? Well, it was great.
28:42
And I think it just becomes so obvious when you see it, right.
28:47
I mean, I mean, forearm is weaker and and can't hang on to
28:51
what we're being tasked to do it with.
28:53
And you guys are adding actual information to that.
28:56
So, you know, on my end, it's like it's much less about
28:58
figuring out, I think what exactly the problem is and more
29:01
about like applying a solution to it in real time, which is I
29:05
think the next step. And in my perspective, and I, I
29:08
think I can come from a slightly different one because I'm
29:10
surrounded by so many people with, you know, an academic
29:13
background and, and more of, of an on the field, you know, type
29:18
of personnel. But it's, it's about that
29:20
transition and it's about helping people understand, OK,
29:23
what is actually the issue in, in normal language, right?
29:26
And just the, the usual language that people use.
29:28
And I think the baseball coaches use a much different language
29:31
than, you know, you guys do. And for me, it's about
29:33
translating the issue and about understanding it and then about
29:36
making sure that so many different parties who are
29:38
involved in player development process understand what's going
29:41
on and how to actually apply it within our system.
29:43
So I think breaking it down in this way makes it much more
29:46
simple to understand so that we can actually make those steps
29:49
and actually applying it. And that's that's really huge I.
29:52
Totally agree. Emily, what are your thoughts
29:54
after hearing Drew and Toby's presentation?
29:56
Yeah, I love the presentation. Thank you, guys.
29:58
Some really exciting work. And I think my big take away is
30:02
just the importance of specificity.
30:04
Obviously we've known in both the baseball rehab and sports
30:08
medicine side and the baseball performance side that the
30:10
strength of the forum is important.
30:12
But being able to narrow down exactly which muscular tended,
30:16
muscular tendedness units are at play and then knowing that the
30:20
leg tension relationship that we train them at and the positions
30:23
that we're training them in are so important.
30:25
And you know, we talk about physical therapy all the time.
30:28
Don't guess, measure it. And being able to actually
30:30
measure, you know, where these guys are at per how hard they
30:34
are throwing and have these benchmarks kind of like you
30:37
mentioned for return to play decision making to get them back
30:40
out there. But I think just the main point
30:42
is that not all forearm training is equal.
30:45
And if we aren't training in those specific ranges, at those
30:48
specific, you know, length tension relationships that guys
30:52
need when they're pitching, that we aren't necessarily targeting
30:55
what we need to be targeting. So specificity is so important.
30:58
Yeah, absolutely. Real quick, before, before we go
31:01
any further, we had a comment from the chat which is also
31:04
really important to layout there and to state with regards to the
31:08
study how it's conducted and also conflicts of interest which
31:11
are important to disclose as you're having these discussions.
31:15
And so for me personally, I'll say I have, I have no conflict
31:17
of interest with the with the company or with the equipment
31:21
that was being tested in this study, Surely no financial
31:24
conflict of interest. I would say that my my conflict
31:27
is the fact that this is something that I'm passionate
31:28
about. And I do think that the folks
31:30
that are behind the the implement that was used and
31:33
tested are also passionate about trying to do whatever we can to
31:36
learn further and to help overhead athletes.
31:38
And so for me, I've got no financial relationship with the
31:40
company. I do help with some research
31:42
side of things and a lot of that is independently spurred.
31:45
So not necessarily questions they bring to me, but questions
31:47
that that I or others generate and then and then use some of
31:51
their equipment. But Mike, Emily, just can we
31:54
disclose any type of conflicts that you may have related to our
31:58
discussion here today for our our viewers?
32:01
I would say I have no conflict of interest.
32:04
I have no financial relationship with Flexwork good for the
32:07
company and no prior relationship with your academic
32:12
institution either. So no disclosures for me.
32:16
Yeah, same with me. It's the first time I've met the
32:18
three of you outside of Emily on this panel.
32:21
So and then you know the flex Pro grip side is just a very big
32:24
just supporter of those guys and what their vision is, but
32:26
certainly without any kind of financial.
32:28
Gunner, are you available yet? Or if not, we'll keep going.
32:31
So look, just to echo what what Mike and Emily said, I, for me
32:35
personally, I completely agree. The granularity of the data that
32:39
we're getting here is important to take that next step, right?
32:41
We've known that the flexure pronator group in general is
32:45
critical, right? It's critical for supporting the
32:47
underlying ligament for dynamically stabilizing the
32:49
medial elbow. But what does that mean?
32:51
And so by this study, we highlight that we can, we can
32:55
get granular data and we can attack weaknesses in a very
32:57
specific way. And to Mike's point, I, I use
33:00
numbers because I feel like my athletes want to have a, you
33:03
know, we're in the gaming world. You know, they like to have a
33:06
score, They like to have something that's that's in front
33:09
of them to to go off. And so I use it from the rehab
33:12
side of things or the return to throw side again, I'm maybe I'm
33:14
putting the cart before the horse with regards to to these
33:18
numbers and the potential preventative way and the
33:22
prediction of risk. But I just say, look, hey,
33:24
here's the numbers, here's where you are and you're weak.
33:27
Look at this number compared to this number.
33:28
I need you to, I need you to work on this.
33:30
And I think that athletes really internalize that and they
33:33
appreciate having a score and having some, some objective
33:36
data. And so that's how I use it
33:38
clinically. Now we're getting some questions
33:39
in the chat. Thank you for all who are who
33:41
are putting in some some great questions here.
33:43
We're going to start moving through.
33:44
We're going to simulate some discussion.
33:45
Anything that pops up, please, please throw into the chat.
33:48
So for Toby and Drew, just we had a question, question, can
33:51
you review inclusion, exclusion criteria, how we got these two
33:55
cohorts and also the timing of data collection relative to
33:59
their their injuries? Yeah, absolutely, Doctor, I can
34:03
touch on that right quick. I think I scrolled through some
34:05
of the questions here and I think I saw inclusion criteria
34:09
as well as like where that sample was obtained from.
34:11
So I feel like I can knock those two birds out with one stone
34:13
right here. Simply put, so these
34:16
individuals, the participants in our study, they were collected,
34:20
the information was collected from players or pitchers that
34:24
came from Driveline and 3D one colleges that utilize the Flex
34:28
Pro Grip and have trained trainers that know how to
34:31
utilize that device in order to enact our strutting protocol
34:35
precisely. So that was where we collected
34:38
our cohorts from. Now the specific inclusion and
34:42
exclusion criteria, the inclusion criteria was going to
34:46
be for the injured cohort would be a primary playing position at
34:50
the pitcher and a medial elbow injury within three years of
34:54
flexion strength reading for the injured cohort.
34:56
So that needle elbow injury had to be a sprain, strain, tear,
35:01
recent surgery for repair or adjacent joint pain.
35:04
So that was the inclusion criteria.
35:07
And then exclusion criteria would be any sort of upper
35:09
extremity injury that really had no direct impact on the flexor
35:16
flexor group or the UCL specifically.
35:18
So for example like an electron on fracture that would have led
35:21
to you being excluded in the study.
35:23
That was one specific example. And then of course all that
35:27
information is de identified, but that was going to be like
35:30
our sample or where we collected that sample from and who was
35:33
allowed to participate in it. And, and Toby, it's important
35:37
to, you know, that's the inclusion criteria and the
35:39
inclusion criteria can affect your interpretation of the
35:42
studies, right? So the injury designation was
35:44
within three years of the testing.
35:47
So that brings up the question, are these these findings, are
35:50
these positive findings because these athletes after an injury
35:53
or after a surgery are just not quite back to normal yet.
35:56
So if we had a, if there was a larger range, time range for the
36:00
inclusion criteria or maybe if we follow these out over time,
36:03
it's possible that these things normalize, right?
36:06
But but we know that guys coming back from UCL reconstruction at
36:11
the first year are not really back, right.
36:13
If we we get granule and we look at performance metrics, they're
36:16
not quite back. It takes them longer to that two
36:18
to three-year mark for some of the stuff to normalize.
36:20
So it's possible that we're catching them on the downslope
36:23
of their injury or surgery and that they will get stronger down
36:26
the line. So important to highlight your
36:28
inclusion criteria may affect the interpretation of of the
36:31
findings. That's exactly correct, yeah.
36:34
Another question was, did you look at velocity, age
36:40
competitive level between those two cohorts?
36:44
Are we, are we comparing apples to apples for the guys, the
36:47
injured guys, 98 mile an hour throwers versus 89 mile an hour
36:51
throwers and the uninjured? Give us a little more detail
36:53
there. Yeah, that's an excellent
36:55
question and super important to consider with our samples being
36:59
relatively larger. So with the north of 32 and 42,
37:03
for the injured and uninjured cohorts specifically, we did not
37:07
standardize across pitching velocity or age.
37:10
But given that our sample was strictly taken from driveline
37:14
pitchers as well as D1 pitchers, we were going to, we were
37:19
basically operating on the assumption that the participants
37:21
within those locations are within those organizations we're
37:24
pitching obviously at a certain competitive level and therefore
37:28
standardized within the sample. There was no one to one matching
37:32
as far as age or velocity. And I think I also saw somebody
37:36
bring up a question about body mass.
37:38
That was not a one to one match on that either, but it was
37:41
simply just a matching as far as the sample was coming out of the
37:44
same locations or organizations for the injured and uninjured
37:47
cohorts. Told you to take that further.
37:51
You might want to in the the next kind of rerun of the stats,
37:54
get some of the demographic data and make sure that you you know,
37:57
you can present demographic data of the two cohorts so the
38:01
readers can understand if there's if they're baseline
38:03
differences. For starters, this is a This is
38:05
a great Emily question here. Emily, hearing hearing this
38:09
research, how does this apply to other sports besides baseball?
38:13
Somebody who trains a wide variety of athletes?
38:15
What are your thoughts on incorporating these findings
38:18
into your practice? Yeah, that's a great question.
38:22
And I actually use, so I own a Flex Pro Grip device.
38:26
I bought it full price and I pay full price for all my
38:28
subscriptions for all my athletes.
38:30
But I use it actually a lot with my NFL players.
38:34
People don't talk about this nearly as much, but I UCL tears
38:38
are not uncommon in the NFL, especially with defensive
38:42
players. So guys who are tackling a lot
38:44
of lineman, linebackers, and I've even had some defensive
38:46
backs have torn their UCLS as well.
38:48
Now in football, we really never surgically repair them, but a
38:52
lot of times you'll see guys just go out and play with those
38:54
giant elbow braces. So I have three guys on my
38:58
patient, Ross right now that do not have Ucls, full, full grade
39:01
thickness tears and they're back playing.
39:04
And we use the Flexpro grip to test them.
39:06
And interestingly enough, we find all the same strength
39:09
imbalance patterns that we do with pitchers who had UCL
39:12
injuries. So primarily the FDS mid finger
39:14
flexion tends to be the weakest. And so we use the Flexpro grip
39:18
both to rehab them back and to test for return to play
39:21
readiness. So that's a big one with the
39:25
easiest correlation for me is literally UCL injuries with NFL
39:29
players. And what they're returning to is
39:30
a little bit different, but the testing and training looks
39:33
really similar. And then I think any overhead
39:36
athlete like tennis and volleyball where you're getting
39:39
similar arm swing motions and valgus loading at the at the
39:43
medial elbow, it can really help with performance.
39:45
Looking at the strength, you don't see as many UCL injuries
39:48
in those sports, but performance is very predicated on forearm
39:52
strength in both of those sports as well.
39:54
So I think being able to test more in the performance side,
39:56
specifically for overhead volleyball athletes and tennis
39:59
players, I think there's I think there's there's great usage
40:03
there as well. Yeah, completely agree.
40:05
And you know, my practice I've had just in the in the past
40:07
couple days, defensive line, defensive end, the UCL injury
40:11
treating non operatively. And and we're just talking about
40:14
a professional tennis player with the UCL too in the same
40:18
same concepts apply with regards to the importance of the flexor
40:21
protein or musculature. Mike, can you talk about how
40:24
you're using these strength assessments or training goals
40:28
within your throwers within the organization?
40:31
I can't because it's, it's simply on the medical side for
40:34
us right now. And so I can't go into detail on
40:36
what we're doing within the organization, but I'm happy to
40:38
go into it kind of more practically and and how I think
40:42
it benefits just put this in general.
40:44
Yeah, or what I practically. You know, I think, I think a lot
40:47
of the time, like you look at, you know, the injuries that have
40:49
happened over like the course of our game and I, I don't have any
40:52
data on this to confirm, but it feels like shoulder injuries are
40:55
really taking a backseat in terms of how common they are.
40:58
And I think shoulder injuries are, are probably arguably more
41:01
serious than elbow injuries in terms of like its impact on guys
41:04
careers going down the road and you just see far less of them.
41:07
And I, I credit the strength and conditioning industry so much
41:11
with, with helping shoulders to decelerate and understanding the
41:14
problem. And it's interesting to see this
41:15
problem kind of occur because they, I think it coincides with
41:19
the stuff that's that guys are throwing now and, and have to
41:22
throw in order to, to be paid the money that they're being
41:24
paid by the industry right in, in Major League Baseball.
41:27
And how that kind of works its way down into college and high
41:29
school and even with kids and chasing velocity and chasing
41:32
stuff so that they, you know, make their team and, and
41:35
eventually make, you know, the money that they're looking to
41:38
make. So I don't think the answer is
41:40
like, you know, don't make these guys as good, right?
41:43
I don't, I don't think that's like, don't let them throw as
41:45
hard. I think if we have to protect
41:47
the elbow, you know, from where the game is and involve our
41:51
understanding of how to apply our knowledge of the human body
41:54
to baseball in the same way that we did with with shoulder
41:57
injuries. And for whatever reason, whether
42:00
it be, you know, pitch counts and, and you know, however, the
42:03
industry has tried to attack it publicly.
42:06
I don't think we found that answer until, you know, the guys
42:09
from Flex progrip came along and, and tried to under and
42:12
really like highlighted the issue of, you know, I think it's
42:14
a forearm strike this year. So I believe heavily in that
42:17
this is the, the, the path forward for, you know, maybe not
42:22
eliminating that issue. I don't know if you can truly
42:24
eliminate it, but at least putting a large dent in how
42:27
often they occur and understanding them.
42:29
And I think that specifically just squeezing something, I mean
42:32
to Emily's point before it's just squeezing something with a
42:35
hand dymometer or, or forearm strength in general versus the
42:39
actual strength of each finger in different directions to make
42:41
sure that we're covering the strength of muscles that are
42:44
surrounding UCL just makes too much.
42:46
And then to do it, you know, where you can calculate exactly
42:50
how much strength and rate of force production is happening
42:53
and measure it and recalculate a strength spraying program.
42:56
So I just think that understanding how those muscles
42:59
need to be strengthened and applying it to each an
43:01
individual person is, is a huge step in the right direction for
43:04
solving that problem. No, absolutely.
43:06
And we're getting a couple of questions about some performance
43:09
related topics. And and I do know that the folks
43:13
involved with the company or flex per grip will be.
43:16
I know that they're willing to set something up on the side to
43:18
demonstrate some of the stuff that they've that they've done
43:20
with regards to looking at spin rate and and some performance
43:23
and training side of things, which is is not exactly what
43:26
Toby and Drew what we're looking at today.
43:28
And I think that's probably better off if they set up a, a
43:31
separate presentation, to be fair.
43:33
And that's actually the first thing that they showed to me
43:37
with some of the white paperwork that they're that they were
43:39
looking at as far as are these things trainable with regards to
43:41
spin rate. And that's one thing I liked and
43:43
appreciated because you got to get athlete buy in.
43:46
And I think that many athletes will trade a flash and they'll
43:51
put stuff at risk for a flash in the pan for, for an opportunity,
43:54
right. And so coming from the medical
43:56
side, although that's where I live and exist, and that's where
44:00
some of some of us also live there, you don't always get
44:02
that. You don't, you don't always
44:04
connect with them. And so I think coming on them
44:06
from a hey, look, if we can do this, this may have some
44:09
performance benefit to you. All of a sudden their ears pick
44:13
perk up and then on the back end, I can say, and also
44:15
actually we might be able to do some monitoring and some some
44:18
targeted, you know, stuff to try and help you.
44:19
And so I'm going to let them present to you guys.
44:23
If anybody is interested, just reach out to to Darrell or Adam
44:26
and I'll have them show some of the stuff they've been working
44:28
on. I think it's a little bit
44:29
outside the scope of what we're talking about today.
44:30
But Emily, the other things that you can measure.
44:35
So importantly, this study with Drew and Toby, we're looking at
44:38
peak flex, your strength right in that testing protocol.
44:43
But people are asking about rate of force development.
44:46
There's other things that can be tested here.
44:47
And are you incorporating that into your practice, Emily?
44:50
Does it, do those numbers mean anything to you?
44:54
We generally when we're testing athletes, rate of force
44:57
development does mean something to me.
44:59
In particular when I am testing for arm strength FDPFDS using
45:03
the Flex Pro Grip, I don't use rate of force development nearly
45:06
as much as I would. I'm testing things like
45:08
hamstrings for sprinters and stuff like that.
45:11
And the reason for that is what we know about the muscular
45:14
tenderness unit of that common flexor tendon is that part of
45:18
the reason why it mitigates UCL injury so much is because it
45:21
minimizes gapping at the joint. And that's specifically mostly a
45:27
tendon property. So there's basically, so we can
45:30
measure strength and performance of the forearm and we can
45:33
measure change in that strength and performance.
45:34
And it's generally 3 reasons why you get a change in that
45:36
performance. And it's either a neuromuscular
45:40
change. So the actual neuromuscular unit
45:42
gets more efficient at firing and hypertrophic change in the
45:46
muscle belly or stiffness of the muscular tendonous unit, all of
45:50
those can produce strength changes and the stiffness of the
45:53
muscular tendonous unit. To train that we largely get
45:57
those tendonous change tenderness changes with
45:59
isometrics. So that has much less to do with
46:02
the rate of force development as it does with training these
46:05
longer sustained holds at at a high Rep Max.
46:10
So greater than 70% Rep Max, we're going to get those changes
46:12
in muscular tendonous unit tension or stiffness.
46:17
So it's not that rate of force development in general doesn't
46:19
matter for athletes. But specifically when we're
46:21
looking at the forearm, I use rate of force development much
46:24
less than I use the total strength of that forearm.
46:27
And then training, we're not doing a lot of like quick
46:29
ballistic plyometric type stuff that would train, that would
46:32
train rate of force development. We're doing much more isometric
46:35
long hold sustained stuff to try and get that change specifically
46:38
in the muscular tendonus unit and not necessarily like I said,
46:41
that neuromuscular quick firing change.
46:44
Yeah. No, I think you dropped a lot of
46:46
knowledge on us there with that. But I tend to agree.
46:48
But I think it has to matter to some extent, right?
46:52
I think that all those things are important to be aware of.
46:56
I don't know how to perfectly use it in practice yet, but it
46:59
makes sense. There's an underlying muscle
47:01
tend to stiffness role being played, but there's also a
47:04
dynamic stability role to be a plate.
47:06
So you would imagine that if the rate of force, you know, a
47:09
thrower with a, a more rapid rate of force ability to deliver
47:14
force, which is what we're measuring with rate of force
47:16
development can maybe with poorly sequenced mechanics can
47:19
maybe recover, right. Versus say as a thrower gets
47:23
slightly out of their kinematic sequencers, has some slight
47:26
biomechanical change, whether it be fatigue or whatnot and they
47:29
don't have that rate of force development, they might not be
47:31
able to cover themselves in that position.
47:33
So I think theoretically it makes sense.
47:35
I just don't know how to, I don't know how to practically
47:38
incorporate it quite yet. Question here about acute to
47:42
chronic workload and its impact on flexor testing injury rates.
47:47
One part of this is for Drew and Toby.
47:49
Any idea where these the testing was done with regards to within
47:52
the season for these throwers? That's a great question.
47:57
I can't specifically speak on when in the throwing season it
48:01
occurred. I do know a vast majority of the
48:03
driveline participants that were in it were actually at the
48:06
beginning of this of their training at the driveline camp.
48:09
I do think that it is also important to like remember just
48:12
like statistical test wise, we're going to get nerdy about
48:15
the numbers. You know, by providing like an F
48:17
test and the Shapiro Wilkes test, it kind of standardizes if
48:21
it passes the test, of course it standardizes the variance and it
48:24
standardizes the normality between and uninjured cohorts.
48:28
So it's kind of safer statistically to assume that the
48:31
bell curve between the two is the same if it passes the test
48:35
and of course the variances. So you could include like
48:38
standard deviation, of course, as a function of variances, they
48:41
are also equal. So therefore the spread is the
48:43
same. So in that way it kind of make
48:46
sure that the injured and uninjured cohorts follow along
48:50
the same lines there. But as far as specifically
48:52
talking about like data collection as at time of the
48:55
season or time of a throwing schedule, I was not performed.
49:00
Mike, any comments on acute to chronic workload and with
49:03
regards to managing your throwers, that's probably a
49:06
topic for a whole another hour long zoom here.
49:08
Yeah, it's sure for sure. I'll try to simplify.
49:10
I mean it is extremely important.
49:13
I mean just how built up they are.
49:14
I, I really like to, compared to strength and conditioning
49:17
training, like you wouldn't just go and squat every day as much
49:20
as you can for the next week, like you're just going to hurt
49:22
yourself in that way. So, you know, spacing yourself
49:25
out and causing your body to adjust is, is really important.
49:28
And I think there's a lot of talk on workload right now, but
49:31
I, I don't know how measured it all is.
49:33
And that's where acute to chronic really comes into place.
49:35
How specific we can get. I will say, I think there's too
49:38
little throwing and I think there's too much throwing.
49:40
I've seen a lot. And then I was involved in a
49:42
Washington Post article recently that suggested that more
49:45
throwing might be the answer. And it certainly could because
49:48
you're forcing the tissue to adjust to throwing, right?
49:51
It's one way to do it, but I think there's more ways to do
49:54
it. And I think you can do too much
49:55
throwing in addition to too little throwing, right?
49:57
We want the tissue to be able to adjust to what you're giving it
50:00
so that it's prepared properly. So finding that ratio, but also
50:05
having a blend of the art and science and not just going
50:07
completely on analytics and completely on numbers and and
50:11
teaching guys to feel what they're feeling within their
50:13
arms and to when they give themselves a break or when the
50:15
push themselves. I think it's also important.
50:17
So meeting somewhere in the middle on those two.
50:19
Yeah, I think you're totally right.
50:20
I mean, we see it, you know, get the question all the time in the
50:23
clinic about, you know, should we be throwing year round or do
50:26
we need to deload period? And the answers probably for
50:29
some throwers, they would probably do better off throwing
50:31
year round, while others might need a shutdown.
50:32
I mean, everybody's different and and from treating higher,
50:35
you know, guys, there's some higher level guys that really
50:38
know how to keep their arm healthy and some of them just
50:40
feel better throwing, throwing year round, but that doesn't
50:43
mean that they're redlining year round or they're pitching year
50:46
round. I mean it.
50:47
And so, you know, again, this is this study looked at
50:51
association, right? So we don't really have that
50:54
predictive factor, but that's the value of some predictive
50:58
factors. If we have them right, we can
51:00
use it for monitoring, to help throwers as they're guiding
51:02
through this, this part, right? Can they keep throwing or do I
51:05
need to deload? Well, if we know that there's
51:07
something that we can watch, right, that increases your risk,
51:10
that might be an opportunity to interview.
51:13
Look, we're going to have to peel you back from this and
51:14
we're going to target your rehab in in a certain direction.
51:18
Right now, we don't know that for sure based off of this data,
51:20
but but we do have some suspicion that this ratio
51:23
matters to some extent, whether it's an association or
51:26
predictive factor. It's an association, whether
51:29
it's a result of injury slash surgery or if it's predictive of
51:32
injury is, is yet to be determined.
51:35
Emily, what are your thoughts on that?
51:36
I'm sorry you cut out just a little bit at the end.
51:38
Can you repeat the last part? I'm sorry, sorry about that.
51:41
What are your thoughts on utilizing potentially predictive
51:45
factors for as you're guiding athletes on whether they can how
51:48
to tailor their volume? Do they need more volume or less
51:50
volume to to progress as a as an athlete?
51:54
Yeah, I land a little bit more on the spectrum.
51:58
Most throwers probably need to be throwing a little bit more
52:01
than they are and I for some athletes, but I think you have
52:04
to take the full athlete profile into consideration and you have
52:07
to look at injury history. What they've been doing with our
52:09
current string conditioning program is like, and it's a hard
52:13
one, it's really a hard one. But when we look at hypertrophic
52:17
changes versus muscle loss, when we shut down, it's a 3 to 1
52:20
ratio, right? So we lose muscle mass three
52:22
times as fast as we gain it. So when we're fully shutting
52:26
down, I think a lot of times we actually don't give guys enough
52:29
time to ramp back up. So then we're in an underuse
52:32
situation and guys are not prepared for the loads that
52:34
they're throwing. And so then we that's where you
52:36
get into the acute versus chronic workload issue because
52:39
in the acute it's too much workload.
52:41
But if you look at the chronic overall picture, they were under
52:44
prepared. But because they were under
52:45
prepared on the longer term scale, they had an acute
52:49
workload issue. So we see all these elbow
52:52
injuries that look like in the moment acute workload issues.
52:55
So we think that we need to throw them less and be more
52:57
protective of the elbow. But really the issue is they
52:59
were under prepared and they weren't throwing enough and they
53:02
didn't basically they wouldn't get to the point where they got
53:03
to build up that endurance for what they're doing.
53:07
Because you know, it's, it's a marathon and a Sprint for
53:10
throwers, right? Like it's a marathon and that
53:12
it's an 8 month season if you're including spring training and
53:15
you know, things like this. But it's a Sprint and that in
53:17
the moment, it is a singular Max effort ballistic situation where
53:20
you get anywhere between, you know, a minute and a minute and
53:23
a half to rest in between pitches.
53:25
So Eileen, I tend to be biased a little bit more towards, I think
53:29
a lot of our long term throwing programs need to increase the
53:32
chronic work to decrease the acute workload issues, if that
53:36
makes sense. Absolutely, it looks like we got
53:39
visuals on Gunner here. Yeah.
53:41
And I really apologize. Sorry that I had one of those
53:45
drives that was you just it couldn't make it up.
53:48
The right lane was closed and the left lane was closed and
53:50
there was a disabled vehicle. And then once I got off of 7781,
53:55
there was another disabled vehicle.
53:56
So I apologize, I was able to listen to the entire
54:00
presentation. I just want to say great job on
54:02
the presentation and lots of also really great questions
54:06
here. I'll just add in that we are
54:08
also here at Virginia Tech. We do have a small prospective
54:11
study going and we're looking at I guess tissue changes are
54:15
related to the use of the Flex Pro Grip device.
54:17
In other words, looking at elastography is a specific
54:21
ultrasound technique that can be used.
54:23
We have a really high end research grade ultrasounds.
54:27
And so that's one of the things things we're looking at is what
54:29
about tissue stiffness as Emily mentioned it, you know, there's
54:32
there's active and passive restraint, so to speak.
54:35
And so I think that's helpful from that perspective.
54:38
And hopefully as we get more data, we'll have more insight on
54:41
to this aspect of is the onercollateral ligament affected
54:46
by a training program? What about the specific muscle
54:48
tendon units? And then the other thing that
54:51
I'll mention is, is a concept that's kind of general, but just
54:54
the whole idea of integrated isolation.
54:56
In other words, we're isolating these specific muscle tendon
54:59
units, looking at at the strength characteristics that
55:02
they have, but they also have to function in an integrated way in
55:05
the forearm in order to successfully pitch a baseball.
55:08
And I think that's a concept that works for lots of muscle
55:11
tendon units and the and the joints that they influence.
55:14
So that concept of integrated isolation.
55:16
And I think this device is something that allows us to get
55:19
at that in a way that we've not been able to do before.
55:22
And just to close the loop on the whole conflict of interest,
55:26
if friendship could be a conflict of interest, I've done
55:28
Darrell and Adam for a better part of 40 years.
55:33
And so we've been friends for a long time, but I don't have any
55:35
financial conflict of interest. So just letting letting you know
55:39
that. And thanks for the great
55:41
questions and putting this seminar on and thanks to all the
55:43
panel members. And again, sorry I was a
55:45
laggard, but I appreciate the opportunity at least to get in
55:48
the tail end of this there. You go.
55:52
Well, thank you, Gunner. Sorry that you had the rough
55:53
travel, but I'd like to, you know, wrap this up.
55:56
We're getting to the we're at the top of the hour here.
55:58
So again, Toby, Drew, thank you for for presenting your work
56:03
here. Great work.
56:04
I think we're leaving with more questions and answers, which is
56:06
exactly how this should be, right?
56:08
This should stimulate some thoughts and stimulate the next,
56:10
the next wave of research. Thank you, you know, for Emily
56:14
and Mike for sharing your expertise for, for joining
56:16
today. Thank you for all the great
56:17
questions in the chat. There are a few things that we
56:20
didn't quite get to. We're going to circulate this to
56:21
our panelists and, and our authors here to go ahead and
56:24
answer, to go ahead and answer some of these questions.
56:26
And we'll we'll recirculate to everybody who's joined.
56:29
But again, thank you for joining, thanks for everybody's
56:31
passion here and that we're all pulling in the same direction,
56:33
just trying to help our throwers sort of pursue their next level
56:37
of performance while also keeping them healthy and, and
56:39
putting them back together when when things go awry.
56:41
So thanks again. I hope everybody has a great
56:44
rest of the day and then until next time, we'll see you later.