Latest / The Layback Podcast / Baseball Rehab Network's Redefining UCL Rehab: Data-Driven Guidelines from Surgery to Competition (Ep. 86)

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Baseball Rehab Network's Redefining UCL Rehab: Data-Driven Guidelines from Surgery to Competition (Ep. 86) · The Layback Podcast

0:00
Hey everyone, welcome back to the Layback Podcast.
0:02
Nobody joining us today, but we will have the presentation of
0:07
another webinar. This webinar is going to be
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brought to you by the Baseball Rehab Network.
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You might be wondering what the Baseball Rehab Network is, and
0:17
the Baseball Rehab Network is something that we are getting
0:20
started to help rewrite and revolutionize how injuries are
0:26
treated in baseball. We got started by attacking UCL
0:31
rehab. Today's presentation is
0:34
officially titled Redefining UCL Rehab. data-driven Guidelines
0:39
from Surgery to Competition. So what this will cover is a 25
0:45
page evidence based guide with over 80 citations.
0:50
A step by step training protocols for how to treat and
0:56
train the muscles most important to protecting the UCL and
1:00
ensuring that we're reducing risk in the process.
1:04
A10 phase rehab overview and three different return to throw
1:08
programs that are base guidelines.
1:11
These programs are customizable, they aren't set.
1:15
They're designed to be dynamic, to work with the individual.
1:18
But all of this, specifically this project I should say, is
1:23
being presented by the following.
1:25
So you will hear from on this presentation, Doctor Gunner
1:30
Brolinson, Dr. Matt Fury, Darrell Morrow, and Dylan
1:33
Newcomer. Also as a primary author is
1:37
myself, which is pretty cool to say.
1:39
And then contributing authors that helped us along the way
1:43
with this project gave us their time, energy, effort.
1:47
Special thanks to Emily Fareed, Josh Hedgeka, Jeff Leatherman,
1:52
Dan Mahoney, Chris Martin, Casey Mulholland, Nolan or pay and
1:56
Ryan Yoshida. Tons of Lay Back podcast guests
2:00
on there. So thank you very much to all.
2:03
It's been an awesome community to work with.
2:07
We're very much looking forward to, as I stated earlier,
2:11
revolutionizing the way UCL and elbow injuries are treated in
2:17
the world of baseball. This was a tremendous start.
2:20
Looking forward to listening back to this webinar.
2:25
Thanks a ton to all who attended and definitely reach out with
2:29
any questions because after this webinar goes out, we will also
2:32
be answering some questions from the Q&A that came in during the
2:37
presentation and we want this to be an ongoing conversation.
2:41
We know this is not where the bus stops.
2:43
This is just a start to working towards something better.
2:47
You guys will hear during the presentation, Doctor Matt Fury
2:50
said something super powerful. He said this is just our take.
2:54
This is a drop in the bucket for what ultimately needs to be done
3:01
in the greater baseball rehab space, but we saw a problem and
3:07
we took our first shot at fixing it.
3:08
Hopefully you guys learn a lot along the way.
3:10
Hopefully this stirs up some questions and gets the
3:14
conversation rolling. Thanks to everyone who attended
3:16
the webinar and to all those listening in today, thanks for
3:20
laying back with us. Well, we're a couple paths, so
3:24
let's go ahead and get started. I'm sure we'll have others
3:27
continue to trickle in as as we get forward.
3:30
So First off, more than anything else, thank all of you guys for
3:33
coming. We have a lot to cover today and
3:35
we'll try and allow some time at the end of the presentation for
3:38
questions, but we know going in we won't get to everyone's
3:41
questions. So what we will ask you to do is
3:44
as you have questions, just put them in the chat box and
3:47
whatever we don't get to live, we will commit to you.
3:50
We'll go through it. We'll list the questions that
3:53
every single person has asked and not by name obviously, but
3:57
then we will answer all of those questions and distribute that to
4:00
everyone who signed up. So even if we can't get to your
4:03
questions live, know that we will answer your questions.
4:05
With that, let's move forward a little bit.
4:08
For those of you who've been on it, you've heard us just chit
4:10
chatting. So there's four of us who we
4:12
were presenting today and we for in addition to Adam Morrow who's
4:17
our Flexprogrip Co founder have worked been working on these
4:21
guidelines for the past 18 months.
4:24
Each of us would have worked really hard along with the
4:26
contributors that you will see listed on the bottom to try and
4:29
create what we think are really the most evidence based rehab
4:32
guidelines that exist today based on all of the available
4:36
technologies. Our goal today is not to try and
4:40
share with you every single thing that we've identified in
4:44
the documents themselves, which we will be happy to share with
4:48
all of you when we're done. There are kind of four
4:50
components to that. There's a fairly lengthy 25 page
4:56
narrative with full citations. There are step by step training
5:01
protocols in the document as one of the attachments, which really
5:05
show you exactly what we think should be done from a training
5:08
perspective. Truly, from week 1 to the time a
5:12
guy returns to playing full competition, we break that
5:16
narrative into phases so you can see exactly what we think the
5:21
goals and progression should be and the benchmarks to move from
5:24
face to face along the way. And then we identify some very
5:28
specific throwing programs that detail volume, intensity,
5:33
frequency, all match to where a person's at.
5:36
So rather than the one page sheet that people often get when
5:40
they go into a rehab program, we think it's important to create a
5:43
level of customization and that's what we strive to do with
5:46
the throwing programs that we would recommend.
5:49
Now, that being said, probably the most important question that
5:54
we had to answer when we even begin this journey was like, why
5:58
do we need another set of rehab guidelines?
6:01
What's going on in the industry that makes us think that we
6:04
needed to do something different?
6:06
And I think there's probably no one better to answer that
6:08
question right now than Doctor Fury, who's been involved in
6:11
some, I think, some Seminole research surrounding this topic.
6:15
So Matt, do you want to talk a little bit about that and why
6:17
you felt like this was something that was worth undertaking?
6:21
Yeah, absolutely. Thank.
6:22
Thanks, Darrell. The UCL surgery with UCL with
6:27
regards to injury diagnosis, indication, surgical execution,
6:30
we've come a long way right, with regards to the treatment of
6:33
medial elbow insufficiency. But in certain ways we have not
6:37
progressed over time. Historically we've we've talked
6:40
about return to play and that was our benchmark.
6:42
That was our benchmark for assessing surgical success.
6:46
And we kind of did this study a couple years back, which was the
6:48
first to use advanced analytics. And let's go back and look at,
6:51
you know, return to play isn't what the athlete cares about,
6:54
right? It's not what your patient cares
6:55
about. It's not what your your players
6:56
care about. They want to return to perform.
6:59
They want to return to a level that satisfactory them.
7:01
And just simply getting back on on the field is one part of that
7:04
journey, but that is not the end game.
7:06
And so if you go back and use advanced analytics and, and look
7:10
at how these guys are coming back.
7:11
Our study a couple years back showed that number one, the
7:13
percentage of of throwers returning is a little bit lower
7:16
than I think we've colloquially discussed.
7:18
And and two, when they do return, they're different.
7:21
They're different with regards to some pitch movement metrics
7:24
with regards to spin rate. And a recent study by Doctor
7:28
Chris Ahmad, they looked at again, advanced analytics found
7:31
that 70% had failed to, to achieve their prior performance
7:36
within a three-year sort of post surgical follow up.
7:40
And the idea of returning to performance, I think is, is
7:43
critical for these guys because the game continues to evolve.
7:46
You know, these athletes are, are out for 12/18/24 months and
7:51
the game doesn't stop. Average below's continue to
7:54
rise. The pitch design pursuit
7:56
continues, right? These guys just get better and
7:58
better. The game gets better.
8:00
And the athlete would expect of himself to have improved too as
8:03
well. So simply getting back on the
8:05
field is not enough. Simply getting back to where you
8:08
were previously is is behind, is behind your peers.
8:11
And so I think that's where we just had to reframe what our
8:13
goals are and our goal are. Our goals are returning to a
8:17
level of performance that matters to the athlete.
8:20
And so with these analytics, with these these new equipment
8:23
and tools that we have available to objectively measure certain
8:27
factors of the recovery process and to then train them in an
8:31
intentional way. I think we've got a lot of
8:32
opportunity to improve on the rehab side of things.
8:35
Because if you go and look at they have studies that have
8:37
demonstrated that a high percentage of patients have some
8:40
form of a set back along the way, whether it's requiring A
8:43
deload, having some pain that's that's needing an intervention,
8:46
some anti inflammatories or whatnot.
8:48
We just haven't been as good historical as I think we've, we
8:52
have just sort of assumed. And so that's, that's been our
8:55
pursuit here. You know, that's why we worked
8:56
on this for so long, is is we just want to be better.
8:59
Doctor Brolinson, we good. Or do you have anything to add
9:01
to that? No, that's, that's a great
9:03
summary. Thanks for that, Matt.
9:05
Perfect. So with that, the question we
9:08
first wanted to understand is what's kind of the industry
9:11
standard. Certainly all of you are
9:13
familiar with lots of different protocols or variations off of
9:16
some. Mike Reinhold and Kevin Wilk
9:18
produced a a publicly available study in 2024 where they
9:23
outlined what they thought were best practice, return to throw
9:28
guidelines. Then then there's an MO MOB
9:31
standard. And for those on the call for
9:33
Major League Baseball, I think you'll be fairly familiar with
9:36
that protocol. And then we looked at ours.
9:39
And this for us is in many ways the money slide.
9:42
And we'll shape how the rest of the guideline presentation today
9:46
goes. And what we did is we tried to
9:48
identify a host of variables, how others treat those, and then
9:53
how we think our guidelines are different.
9:56
And for the rest of the presentation, what we'll do is
9:59
we'll just go through each one of these to talk about what we
10:02
think is important and why we think it's important and how our
10:07
guidelines go about treating these.
10:09
So whether that's talking about criteria to begin return to
10:13
throw, whether that be general or specific to the elbow, we
10:18
think objectivity is key. We think forearm loading should
10:22
begin earlier than most begin forearm loading return to throw.
10:26
To date we don't differ in any way on when we begin return to
10:30
throw. I think we differ on the
10:32
criteria that shapes whether or not that's going to happen.
10:36
Certainly when we get to throwing intensity and how we
10:39
regulate that in in our return to throw, we think we differ
10:42
considerably because we think Velo and IMU, if it's available
10:46
is considerably superior. But we'll talk a little bit
10:49
about the concept of acute chronic workload ratios and
10:53
using that to manage the return to throw mound introduction.
10:57
Is it a tad earlier than one of the studies and significantly
11:01
than what the MLB standard is? Where we differ considerably is
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when we think we should start introducing change ups and
11:07
breaking pitches and one of our contributing authors, Chris
11:10
Martin was extremely helpful and in shaping some of our thinking
11:13
on that. Then we just talk about the way
11:15
we value throw shows how frequently you have to throw at
11:20
high intensity to get someone ready to truly return, not just
11:24
to play, but to return to a level of performance that gets
11:27
the athlete where he wants to be.
11:29
Then we'll finish just talking about this concept of
11:32
customization and how we customize return to throw in our
11:36
in our model and then spend a little bit of time talking
11:39
specifically about deload weeks and the criteria that we think
11:43
important to return to play. So with that, let's just
11:46
progress and keep moving. First, in terms of the general
11:49
criteria that we think ought to be met to begin a return to
11:53
throw program. And with that we'll turn it over
11:56
to Dylan Newcomer. Dylan has his own private
11:59
practice physical therapy clinic and also is the head physical
12:02
therapist at Driveline. So with Dylan, you want to walk
12:05
us through your thoughts here? Yeah.
12:07
Thank you, Daryl. So yeah, really this whole slide
12:10
is is what we're talking about from day one of rehab up until
12:14
we actually hand an athlete the ball.
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And so before we ever even start throwing, this is the filter
12:19
that I'm going to view everything through.
12:21
A lot of guys end up getting cleared because they feel good
12:24
or because the calendar has said it's six months, but good really
12:27
isn't a metric. Strength capacity and your
12:30
readiness actually are. And so the guiding principle
12:33
here is really simple, don't give a ball to an athlete that
12:35
has an under prepared arm. And if we don't restore that
12:38
baseline capacity first, we're really asking a less resilient
12:42
system to tolerate more stress than what we were asking it to
12:46
do before it got injured. So we'll go through a couple of
12:49
the key points here, but we'll we'll dive into it more later.
12:53
One of the big things for us is internal rotation strength, but
12:56
more consequently the structured reintroduction of valgus loading
13:00
throughout the rehab process. I think it's one of the bigger
13:02
missing pieces in the return to throw aspect or getting ready
13:06
for the return to throw. And we'll dive into that
13:07
specific piece in the next slide.
13:09
But we have studies that show that athletes are being returned
13:13
to throw like getting into that's part of their their rehab
13:15
whenever they're upwards of eight to 10% weaker on their
13:19
throwing side than their non throwing side.
13:22
We're essentially asking them to start doing what's essentially A
13:24
plyometric action on a simply weaker structure.
13:27
And for me, this is kind of like if we talked about an ACL knee
13:31
patient asking them to do high velocity single leg plyometrics
13:35
whenever they still have like a weak quad.
13:37
That's one of our first components.
13:39
Another big component for us is the global lifts.
13:42
And what I mean by is just your general strength, your general
13:45
physical preparedness exercises, your bench press, your push ups,
13:48
your poles, whatever it is that you and your organization and
13:51
your staff are comfortable putting your athletes through.
13:54
We want to get them back to at least 90% of what they were
13:56
doing pre injury before we hand them a ball and before we ask
13:59
them to return to competition. We want them well beyond that
14:02
100% restored and especially as strong as the non throwing side.
14:07
Another component we like to use the ash test for long lever
14:11
force production and we'll show some values later on for that.
14:14
We think that you should be able to tolerate and hit certain
14:17
benchmarks in those positions. And the final piece there is
14:20
kind of an explosive upper body power progression.
14:23
Things like plow push up patterns or being able to
14:25
tolerate high velocity Med ball throws or things along that
14:28
line. Basically having those pain free
14:30
repeatable, no guarding or any hesitation going on.
14:34
And if we can hit kind of these benchmarks from a general sense,
14:37
it feels more comfortable to get the athlete into what we believe
14:42
is a state ready to return to throw when you can move to the
14:45
next slide. For me, Daryl, and this is
14:47
really a big concept for us, is that the internal battle of
14:51
rehab is neurology versus Physiology.
14:55
Physiology takes time to adapt, whereas neurology is much
14:59
quicker and especially if you have athletes that are throwing
15:01
90 plus miles an hour, those athletes are going to be able to
15:05
hit the hit the gas pedal much easier and much faster than
15:08
potentially their physical system is ready to take on.
15:11
And it's when that neurological demand starts to exceed their
15:14
physiological preparedness that the athlete starts to get into a
15:17
position where they might be set up for setbacks or re injury.
15:21
And so our job really is to flip that when physiological
15:24
preparedness is either going to match or exceed that
15:27
neurological demand, we're going to get a much safer progression
15:31
and the athletes body will have the capacity to handle the
15:33
stress that the nervous system is going to be producing.
15:36
And those later stages that the return to throw, there's another
15:39
layer here as well, which is training economy.
15:41
The more of these qualities that we can address before we start
15:45
the return to throw. So the strength, the power and
15:48
just the tissue tolerance overall, the less that we have
15:50
to juggle these variables once we actually start the return to
15:54
throw. If you walk into this return to
15:56
throw stronger, more resilient, the less of an impact that each
16:00
new progression in the return to throw will have.
16:02
And that efficiency really matters because the further
16:04
along we are in that return to throw, the better we are
16:07
physiologically, the more freedom we will have to progress
16:11
that skill safely. All right, So going into this,
16:14
one of the components is our pre loading, our pre return to throw
16:18
valgus loading progression. Historically, most of the UCLR
16:22
protocols start introducing internal rotation and valgus
16:25
loading somewhere around week 8. We don't really differ from
16:27
that. But if you look at kind of
16:29
typically what's described in the protocols, it's usually some
16:32
form of like a throwers 10 band series.
16:35
Maybe you'll see a mention of a body blade and some
16:38
perturbations. And maybe you'll see towards the
16:40
end kind of the introduction of like one arm plyometric dribbles
16:44
and things like that. And these may kind of re expose
16:47
a similar movement to throwing. But there's nothing here that's
16:51
really creating any adaptation or stress.
16:53
And that's really the big difference is like re exposure
16:55
is great, but we need an adaptation to occur.
16:58
So we need a progressive tolerable stress that can
17:01
actually stimulate change in the tissue's capacity to handle that
17:05
bulgus load. And so that's what our
17:07
progression is designed to do. And so we walk through a four
17:09
stage progression first manipulating the volumes or the
17:13
variables of load and velocity. So early on, just like most
17:17
protocols, we start with a lower load and low velocity, basically
17:20
reducing how much of an impulse we're applying to the the graph
17:23
site. So this is really just your
17:25
basic band work and things along those lines.
17:27
The early internal rotation exercises you begin to
17:29
reintroduce. We, we don't differ too much
17:32
here. I believe that BFR is a great
17:35
tool to introduce into this time if you have it, but that's,
17:39
that's another story. As we move through the
17:41
progression, the first variable that we want to move through is
17:45
load velocity is really the variable that's going to impact
17:48
the graph site the most how, how fast that distal segment is
17:51
moving through any internal rotation exercise.
17:54
And so we start to increase the load.
17:56
First things like your heavier IR, slow eccentrics or like high
18:01
intensity isometric holds. That way we start applying a
18:03
stress to the system that is actually high enough to promote
18:06
a adaptation in the area. And then we start teaching the
18:10
graph how to accept a little bit more of a meaningful load.
18:12
Again, as we move further into the rehab series, we begin to
18:17
reduce the load and start to progress the velocity a little
18:20
bit. You can use things such as fans
18:23
or drop catches, or my personal favorite is to start
18:26
incorporating something like a flywheel here.
18:29
And then our final progression leading into the actual phase
18:33
right before you start throwing is to minimize the load as much
18:36
as possible all the way down to potentially something as light
18:38
as a baseball. But you start moving the arm
18:40
much faster through these positions.
18:42
So this may be like oscillatory drills or higher velocity Med
18:46
ball patterns that are actually applying a decent torque to the
18:50
elbow. And the whole purpose of this is
18:52
just to retrain the athlete to tolerate load, move fast again,
18:56
and more, more than anything, be confident in these positions.
19:00
It's when these athletes don't have confidence in their elbow,
19:02
they don't feel like it's actually been trained or
19:04
stressed enough that they kind of enter the return to throw
19:07
with a high degree of uncertainty.
19:09
So now we want to talk a little bit about the specific criteria
19:13
that we think ought to be in place to clear someone to return
19:17
to throw. And it's tough to do that
19:18
without first talking a bit about the injury itself.
19:22
And I think the first thing that we all have to re anchor on is
19:25
this understanding that the UCL injury quite simply is a torque
19:31
capacity problem. You go, you throw a baseball,
19:34
you place a certain degree of valve stress on the medial elbow
19:37
and that has to be buffered by three different structures, the
19:40
UCL, the RC joint and the muscle tendon units which cross the
19:45
medial forearm. And it's a fairly simple
19:49
concept, but but one that I think people often lose.
19:52
And it it's just this, if you're looking at this as a simple math
19:56
problem, what we know is there's a strong correlation between how
19:59
hard someone throws and how much torque they're placing on their
20:02
elbow nearly one to one. Of course, anthropometrics will
20:06
change that. If somebody's longer limbed or
20:08
throwing sidearm, it will differ slightly.
20:11
But from a rough paradigm standpoint, if a guy's throwing
20:15
100, he's going to play somewhere around 100 Newton
20:17
meters of torque on his elbow. But the UCL has a fixed upper
20:21
limit, and it's well beneath that total torque being placed
20:25
on the medial elbow. At lay back, the UCL makes some
20:29
level of contribution up to a Max, let's say a 45.
20:33
We get radio humor joint compression, which might add
20:35
another 35 Newton meters or so. And to prevent a tear, the
20:40
muscle tendon units which cross the medial elbow have to do the
20:44
rest, for which there are three that matter most.
20:48
When you look at this anatomically, those are fancy
20:51
terms, FDS or flexodigitorum, superficialis, ulnaris and
20:56
profundus, and all of them have very different functions, but
21:00
they all serve to cover some piece of the UCL footprint.
21:05
So what we have to do, because we know that we're operating
21:09
with fixed limits on UCL torque and radio humeral compression,
21:14
the goal is to try and make this variable piece contribute as
21:17
much or more than what would be left over to equal that
21:22
mathematical equation. Because if we do that, if we can
21:26
drive this number up, we can shrink the load on the UCL,
21:29
which just puts us in a much better position in terms of
21:32
overall forearm health. That also clearly then has
21:36
implications for us from a rehab standpoint we know just well
21:42
vetted in the literature. And Dr. B, you can address this
21:45
more if you think there's a point that here that needs to be
21:48
stressed. But we train muscle tendon unit
21:53
strength throughout the process. But what we're really chasing is
21:57
stiffness because what we know is that a stiffer muscle tendon
22:01
unit can offload more tensile force or more stress that might
22:06
otherwise be shifting to the UCL.
22:08
So throughout all of our specific both criteria and in
22:12
our training as we focus on foreign musculature, the goal is
22:16
to improve stiffness and overall endurance capacity of these
22:20
muscle tendon units. Doctor Burlinson, anything to
22:22
add to that or is that pretty smart?
22:24
On. Yeah, I think that's well said.
22:26
It's a simple concept, but really key to the whole idea of
22:30
this process being successful. Great.
22:34
So one of the things that we learned in this process, it was
22:38
a study that Doctor Brolinson and Dr. Fury LED, a
22:41
retrospective study. Doctor Brolinson, I don't know
22:43
if you want to speak to this a little bit.
22:45
Obviously, what the biggest take away is it just reaffirm what we
22:49
suspected going in was that weak or forearm flexors were going to
22:53
place people at significant risk.
22:56
And that's when we looked at these two in this retrospective
22:59
study. I know that's what we found, but
23:00
I don't want to steal your Thunder here if you want to talk
23:03
through any of this. So that you're exactly all
23:06
right. So when we started to see this
23:09
and Daryl and I've had this conversation before, many folks
23:12
know I'm at Virginia Tech and we were the first team to
23:15
instrument football players helmets with an accelerometer
23:18
array way back in 2003 when nobody cared about concussion.
23:21
And when what we noticed, well, first of all that you know, that
23:25
was a crazy idea of putting accelerometers in the helmet,
23:28
recording real time head accelerations and correlating
23:30
that with the clinical diagnosis of concussion.
23:33
We were a Riddell team at that time.
23:35
We used the VSR 4 and the Riddell had just produced a
23:39
helmet called the Revolution, which was the anti concussion
23:42
helmet. A lot of controversy around
23:44
that. People thought a helmet makes no
23:45
difference in terms of concussion.
23:47
Long story short, we started to see a divergent in our data.
23:51
The kids that were in the Revolution had much lower head
23:54
accelerations than the kids that were in the standard VSR 4.
23:57
There were several other teams at that point also using what we
24:01
call the hits device. The telemetry system pooled our
24:05
data and sure enough what we found in in the lab, we
24:08
predicted a 50% reduction in in concussion and that was what we
24:12
saw with our actual on the field data.
24:14
So I like to call that a smoking gun and I won't get into all the
24:18
details of that, but that's very similar to what we saw here.
24:21
As we started to look at the data that that we had in, in our
24:25
in our database, we started to see this forearm flexor muscle
24:28
imbalance that was contributing to this or associated with
24:32
Miguel elbow injury. Now you know, this is always the
24:35
chicken or the egg argument, but to me this is a very important
24:38
smoking gun. And as I mentioned, but
24:41
previously we weren't able to measure head accelerations and
24:43
so even get at what kind of helmet design might reduce the
24:47
risk of concussion. So for the first time ever, we
24:50
have a device that allows us to measure this forearm flexor
24:53
strength and and getting put numbers to that.
24:56
So I think that's the really exciting thing about this.
24:58
Of course, much more research needs to be done, but but this
25:01
is the the smoking gun that kind of got us going down this
25:05
pathway. So with that, what we know is
25:09
all of this starts with forearm loading and this notion of when
25:13
we load and how long we should wait before loading.
25:16
And Doctor Fury, as a surgeon, obviously you can start to
25:19
address comfort level and loading forearm.
25:22
So I, I thought maybe you might speak to that for a minute as it
25:25
relates to how early you feel we can start loading forearm
25:28
musculature. You know, I think there's
25:30
obviously there's a spectrum here, right, with regards to
25:32
the, the disease of the medial elbow, there's a spectrum with
25:35
how much of the underlying flexor pronator is involved in
25:40
the injury, right? We're seeing a higher percentage
25:42
of, of throwers having partial tears of the flexor, older
25:45
throwers having, you know, more substantial flexor tendon
25:48
injuries. And so I think there's a
25:51
spectrum here with regards to the initiation of, of loading.
25:55
There's a couple things that we we know and a lot of this, you
25:57
know, driven by Keith Barn and a lot of the work that he's done.
26:00
And, and also there's a lot of, of experience around here too,
26:03
as well as it, you know, early loading is beneficial for tissue
26:07
quality, for tissues to lay down in the appropriate orientation
26:11
for overall biologic and biomechanical properties of the
26:14
tissues. Now, early loading is not
26:17
necessarily the, the fear. I think it's, it's early,
26:19
uncontrolled, unmeasured, unknown loading, which is the
26:22
word right from the surgical side.
26:24
And so I think, you know, personally, I'm, I'm OK with,
26:27
with earlier loading as long as we're doing in an objective and
26:30
measurable way. And I think that that's what a
26:32
component of this program involves.
26:34
And it involves being very measured, very gradual with
26:38
exposing the medial elbow to some of the stresses that we
26:41
know it's going to need the capacity to withstand, right.
26:44
And so that's where we we've started this early loading,
26:47
which again obviously will differ based off of some of the
26:49
various pathologies here, but I think it's the benefit of one of
26:52
the program. Dylan, you want to talk about
26:54
what we're trying to achieve in loading in the early stages, pre
26:58
return to throw and then where we progress from there?
27:01
Yeah. And so when we we talk about
27:03
form loading, the goal really isn't just to, you know, like
27:06
strengthen the arm, strengthen the, OR get hyper pertrophy in
27:09
the tissue or make the form just kind of do stuff like rice
27:14
buckets, therapy, putty, all that stuff.
27:16
Our goal is to create a specific progressive adaptation in the
27:20
muscle tendon units that are there to protect the UCL that
27:24
Daryl talked about previously. And so beyond that, every phase
27:28
of this form loading scheme is designed to have a distinct
27:31
physiological purpose. And if we know what we're
27:34
targeting and how we're going to target it and what's required to
27:37
target it, then we can design A loading scheme that's actually
27:41
makes sense. So we kind of bucketed this
27:45
down. There's a lot more detail in the
27:46
actual document, but to to make it concise and early speaking in
27:50
our weeks 3 to 8 period, we start with kind of our low light
27:55
loading, which is 10 to 30% of 1, our one Rep Max or of our
27:59
targets that are based off of some of the data.
28:01
And the goal here is just to stimulate collagen remodeling
28:04
and healing, provide that healthy environment that Matt
28:07
was just discussing. It really kind of sets the
28:09
foundation for what we want to do later on in this rehab phase.
28:13
As we move into the middle stages.
28:15
This is really where we start focusing in on generating that
28:18
stiffness, adaptation of those key muscle tendon units.
28:21
So we begin to progress the the tensile loading up into high
28:26
intensity ranges that are required to actually stimulate
28:29
that adaptation. But at this period of time, this
28:31
is also where we start to implement some of our ballistic
28:33
loading protocols. So we can prepare the athlete
28:36
for that and what we want them to do in that this final stage
28:39
in the bottom row here. And this is where we continue to
28:42
solidify those stiffness adaptations, but also this is
28:46
when we really start to hammer in on our ballistic application
28:48
of force and our endurance training at higher intensity.
28:52
So that way we not only get a stiffer muscle tendon unit, but
28:57
we get one that can apply its force in a meaningful window of
29:00
time and one that is much more fatigue resistant.
29:03
And then that translates obviously Dylan into return to
29:06
throw. Yeah.
29:08
And so before we jump into kind of the rest of the presentation
29:12
focusing on return to throw, just wanted to wrap this up a
29:14
little concise slide of of what we think we want to accomplish
29:18
before we get to the return to throw and what we want to
29:20
accomplish before we get to return to play.
29:22
And we'll visit that again at the end.
29:25
But return to throw, like I mentioned previously, our our
29:28
big goal is we want the athlete to be within that 90 plus
29:31
percent range of all of their pre injury lifts minus deadlifts
29:34
and pull ups. Those are a little bit more
29:36
controversial and definitely something that needs to be
29:39
considered based off of the athlete and experience and
29:42
tolerance and many other, many other reasons there.
29:45
Flexpro grip testing or whatever form I'm testing you may be
29:48
using. But in our protocol, we're
29:49
specifically talking about Flexpro.
29:51
We want to be at our 70% range at a minimum, but we'd love to
29:55
see athletes greater than 90% of our targets for them.
29:57
And then for their shoulder, both in kind of short lever and
30:00
long lever positions. You can see kind of our criteria
30:03
that we're recommending we utilize a body weight ratio here
30:06
just to kind of normalize that from athlete to athlete.
30:09
But also we are again considering the limb strength
30:13
index or symmetry index there and we want to make sure that
30:16
that throwing side is surpassing their non throwing side.
30:19
OK. So now we're going to move on
30:21
into that return to throw and that's pretty much the focus of
30:24
the remainder of the the presentation here.
30:26
And our model return to throw is typically going to begin around
30:29
weeks 20 to 26. And this is mostly for UCL
30:32
reconstructions. If you have a repair, you can
30:35
shorten this down just a little bit.
30:37
But our big thing is that time is not what's going to heal it.
30:40
It's all the capacity that we've talked about up to this point.
30:43
We want to make sure that we're respecting graph biology in the
30:46
ligament ligamatization timeline and we're not going to rush this
30:50
process. But we also know that roughly
30:53
around week 20, if you've followed the guidelines at this
30:56
point, this is a good time to start that return to throw.
30:59
And one of our big differentiators here that we
31:01
mentioned at the beginning is that we believe that regulating
31:04
throwing intensity is probably the most important thing that
31:06
you do in this entire process. And the big question is how do
31:09
we do so in the past, historically it's been distance
31:13
RPE. Occasionally you'll get some
31:15
Velo guidelines that are relatively non specific and
31:20
could do with a little bit more specificity.
31:22
Definitely believe that distance is is not a good correlation to
31:25
any form of intensity that the arguments been made 100 times.
31:29
You could throw 90 miles an hour at 60 feet or you could throw 45
31:32
miles an hour at 60 feet. It's just not a good measure of
31:35
intensity when you're talking about a rehab protocol very
31:38
similar with RPE. One athlete's RPE of 70% may
31:42
produce a velocity that's significantly different than
31:44
another's. And neither of these methods are
31:46
really good when you start to scale this out population wide.
31:49
So the control stress, we believe that the gold standard
31:52
would be the combination of velocity and utilizing an IMU
31:57
such as pulse or any of the other wearables that are out
31:59
there and monitoring the arm speed and the workload
32:02
accumulation there. But if you don't have an IMU, we
32:06
still believe that the very best option overall is to simply
32:09
utilize velocity throughout the entire return to throw.
32:12
Having as much experience as I've had over the last several
32:15
years doing return to throws in person with, with many athletes
32:18
velocity, if you put a radar gun in front of an athlete, they're
32:21
not just going to suddenly start throwing as hard as you want
32:23
them to do. If you tell them that I want
32:25
this throwing set to be within this velocity range, they will
32:29
stick to it or none, even whenever they go off and do it
32:32
on their own. It's not like they're just
32:34
suddenly going to try to beat whatever you're prescribing.
32:36
Most athletes are sensible enough not to do that.
32:39
And we know that velocity has a pretty strong intra thrower
32:42
correlation. We know it differs from thrower
32:44
to thrower, as Daryl mentioned earlier, but from within the
32:47
same athlete we know that a steady accumulation of velocity
32:51
will be our best approximation of a steady accumulation of.
32:55
So once we say we're going to create a throwing program, the
32:58
real question is at a macro level is how are we going to
33:01
manage this? And over the last five to 10
33:04
years, there's no question that the concept of the acute to
33:08
chronic workload ratio is popularized by Gabbett has made
33:11
its way into baseball. And we think there's great value
33:14
in that. I suspect most on the webinar
33:17
are familiar with it. For those who aren't just a
33:20
brief explanation, the whole concept of an acute to chronic
33:23
workload ratio is to just figure out a way to measure or quantify
33:29
how recent training load compares to a longer term
33:33
training load. There are different variations,
33:35
but most tend to look at an acute training load period or a
33:39
short term training load in seven days.
33:41
Others might use 9 days against the long term training load,
33:45
which would be like a 28 day period and then simply creating
33:48
a ratio of what's happening in the short term over the long
33:53
term. And there have been multiple
33:55
studies that have looked at that and found that ideally you would
33:58
like to have training ranges, whether we're talking about
34:02
throwing or any form of exercise activity in a range of .7 to
34:07
1.3. So the concept there would be if
34:10
you were operating at a 1.3 acute to chronic workload ratio,
34:16
that would be interpreted as saying in your seven day period
34:20
or in that short term period you have increased your workload by
34:24
30 percent, 1.3 over what that chronic load would be.
34:30
And in studies specific to baseball 1 done by Meta
34:34
specifically found that the minute you started spiking ovary
34:39
1.3 workload was when you placed yourself at a significantly
34:44
higher risk of injury. So with that, as we started
34:47
modeling return to throw programs, we wanted to be very
34:50
respectful of that data. Now, if you stay under 1.3, does
34:55
that mean you're never going to get hurt?
34:57
Of course not. If you go over 1.3, does that
34:59
mean you're going to immediately get hurt?
35:01
Of course not. Ratios tend to speak to the
35:05
general experience. And certainly we want to work
35:09
have statistics be on our side whenever we can.
35:12
So with that, we started looking at this concept of creating an
35:16
acute to chronic workload for our return to throw program.
35:19
The challenge with that is it doesn't matter what workload
35:24
program you look at. Ultimately what you're having to
35:27
do is figure out how you're going to value any sub Max
35:33
throat. There is no research, there is
35:36
no study which defines how much torque or stress does a 50%
35:42
throw create on the arm relative to a 75% throw relative to 100%
35:49
throw. Lots of people have made
35:51
speculations and the truth is we have no formal research to say
35:55
that anyway. We can look to the literature
35:57
and try and just reason through what we think makes most sense,
36:01
and that's what we've done with our guidelines.
36:04
I suspect in the future, whether it be us or others, we'll figure
36:07
out a more concrete way to measure this, but that's the
36:10
best we have to go on now. So for example, there are a few
36:13
different ways that do this now. So future chronic workload
36:18
models tend to work within zones of throwing and most tend to
36:23
work within 10 zones of throwing.
36:25
So a zone 10 throw would say that someone is throwing at 100%
36:29
of their Max V low. A zone 5 throw, for example,
36:32
would be someone throwing at 72% roughly of their Max V low.
36:36
A zone one throw would be like a light toss at 50%.
36:40
We've done for an example. And these are all well vetted in
36:44
the narrative that you will see is we create schedules based on
36:49
someone's peak Velo, so in this instance 92 mph and then we just
36:53
set target ranges as to how hard someone should throw.
36:57
Over the course of this return to throw program ulcer, any IMU
37:01
would tend to do this relying upon arm speeds and they would
37:04
create arm speed ranges. So for example, a zone 5 throw
37:09
might be an arm speed of 550 to 650 RPMS, and those tend to
37:16
match pretty well with Velo up until about the 70% range.
37:20
Then there start to be some diversion.
37:23
Most surgeons will use distance and some of the more popular
37:26
surgical protocols would say we're going to use distance, but
37:31
then we're going to match distance to rough approximations
37:35
of Velo. So once we have that, then the
37:39
real question becomes how do you value a throw?
37:42
And for this, we'll be the first to say that our valuation we
37:46
think differs then that of probably the most popular IMU on
37:52
the market, which would be Pulse of the way you would interpret
37:55
this again, all in the narrative.
37:58
So Pulse would value a throw and say that 2.3 throws made at
38:04
roughly 72 percent of a person's Max velocity is equal to 1 Max
38:11
effort throw. In terms of the overall stress
38:14
on the forearm, muscular chore, and shoulder, we think that's
38:19
not nearly an accurate representation.
38:22
We've done a fairly exhaustive survey of 50 plus pitchers and
38:26
just ask them subjectively, how many throws do they think they
38:30
would have to make at 75% of their Max V low to have it equal
38:36
1 or 50%. And you can see we created a
38:39
scale that's almost like a three to one scale over pulse.
38:42
The impact of that means that we place less value on the stress
38:49
of a lower a sub Max velocity throw in terms of building
38:55
capacity for that individual to ultimately ultimately be able to
38:59
make Max effort throws. With this schedule or valuation,
39:04
we can then build out throwing models that essentially go back
39:09
to how we would map this out if we were mapping out in the Q to
39:12
chronic workload ratio. The standard here is if you look
39:16
at the green lines may be a little bit difficult to see, but
39:19
if you look at the green lines that would be that safe
39:21
corridor. The bottom green line would show
39:24
us a -, 7 ACW floor. The upper green line would give
39:29
us a 1.3. The red line would show what our
39:33
Q to chronic workload model is throughout our entire return to
39:38
throw program. As you can see we never ever,
39:42
ever exceed the 1.3 ratio and out and in at any point in our
39:48
entire recommended return to throw program.
39:51
Contrast that to one of the more popular surgical programs out
39:56
there and this is what their program would look like and you
40:00
can see fully at this point they are spiking.
40:04
And acute to chronic workload above a 1.3, we have this, I
40:11
think this says 0, but the truth is it's 24% of the time they're
40:16
actually spiking. And acute to chronic workload
40:19
ratio slide looks like it's slightly off.
40:21
But the point is here, our goal is to be very consistent,
40:26
methodical, so that we keep people in a safe range from the
40:30
first. This would be day seven of the
40:33
return to throw all the way till we're done.
40:35
We're always creating this gradual progressive load.
40:39
And I know, Doctor B, it's something you always talk about,
40:41
this concept of creating real progressive loading throughout
40:44
an entire rehab process. Yep, specific adaptation to
40:48
impose demand. So I mean, that's the key.
40:50
That's what this that's what this speaks to.
40:53
So once we have that in place, then the question becomes as we
40:57
progress through return to throw, when do we start doing
41:01
the things that pitchers really care about is not just moving
41:04
off slack grounds, but getting introduced to mound throwing and
41:07
breaking pitches in the light. And Dylan, you want to touch
41:10
upon this? Yeah.
41:12
And this is probably one of the biggest mistakes that I see in
41:15
the traditional return to throw models is you typically will go
41:18
through a very full long toss progression.
41:20
Many, many weeks go by without ever touching the slope.
41:25
And we just know that you can get on the slope and not really
41:27
have any form of an impact on your stress on the arm of the
41:31
torque accumulation on the arm. And So what we like to do is
41:35
give you a recommendation that roughly anywhere between about
41:38
75 eighty, 85% of the athletes pre injury maximum Velo is
41:44
usually about a good time that it blends well into the slope.
41:47
And earlier you can get the athlete on the slope working on
41:50
the skill of working down the down.
41:54
The more time that they're going to have to seek work on their
41:57
mechanics, get better sequencing and overall just feel more
42:00
comfortable as we try to ask them to progress further.
42:04
We're not a fan of throw a 20 pitchable pin at 50% of 20
42:08
pitchable pin at 75%. Whatever it may be, we want to
42:12
get the athlete on early. We want to continue to utilize
42:15
our velocity progressions throughout this entire process
42:18
and realistically after this point over half of our throwing
42:22
is taking place on the mound. And this also goes into another
42:25
question that we need to answer, which is when do we introduce
42:28
off speeds and breaking ball pitches roughly at the same
42:31
time. Now we typically will allow the
42:33
athlete to get comfortable with the fastball first in these
42:35
positions, but over time we can start to safely reintroduce off
42:40
speeds and breaking balls at the same relative RPS kind of
42:44
velocity based scales as the fastball.
42:47
And we want to on ramp these these pitches early and give the
42:51
athlete a large on ramp time to get these pitches up to speed as
42:56
well. We know from the literature that
42:58
this is not going to place any significantly more torque on the
43:01
elbow. And in fact as you get into
43:03
higher velocities, the fastball becomes the most stressful
43:06
thing. So we can begin to reintroduce
43:08
these pitches earlier, start to expose the form to the various
43:12
positions that those dynamic stabilizers are going to have to
43:15
operate within and use a very similar similar mindset of
43:18
progressing them slowly and specifically with a velocity
43:22
based progression to get it back up to speed.
43:26
And as far as our mix of how much we're incorporating, we
43:30
believe that it should roughly mirror what the athletes
43:33
utilization will be whenever they get back to in game
43:36
pitches. I know there's one caveat to
43:38
that, Matt. It's preliminary for us, but I
43:41
know you've been involved in a study looking at supination bias
43:45
type pitches and I'm not sure if you want to just make a point
43:48
about that. Yeah, so I think, you know,
43:49
Dylan brings up some great points on the the early exposure
43:53
to breaking balls and how for if you look at in the in the lab
43:57
mocap, what not the lower velocity in which he's breaking
44:00
pitches you're throwing at imparts a lower level of force
44:03
in the medial elbow. You know, however, we've done a
44:05
study, you know, here and a lot of this is helping.
44:08
Dylan took kind of a spot analysis of a bunch of healthy
44:11
throwers and we tested their flexor pronator function in sort
44:15
of the position of fastball release versus in a supinated
44:18
position. And we did find that there were
44:20
some differences based off of natural pitch bias.
44:23
And so throwers who were self-described as natural
44:26
pronators did demonstrate some decrease in flexor pronator
44:31
function in a supinated position.
44:33
And so that does again, bring into an area where I think
44:36
we're, we need to be mindful on the reintroduction of breaking
44:39
balls because natural pronators may have decreased flexor
44:43
pronator function in supinated position.
44:45
And we just got to be mindful of how their flexor is functioning
44:48
because we're, we're imparting a different level of force on the
44:51
media level compared to a natural supinator.
44:53
And so again, this is all stuff that we're still learning and,
44:56
and things that we're going to be adapting and, and changing
44:58
overtime. There's going to be stuff here
44:59
that we're going to be wrong about and stuff that we're going
45:01
to adjust. But this just shows the level of
45:03
detail that we're that we're seeking to figure out and to
45:06
titrate. Now, this kind of piggybacks on
45:08
to the concept we were talking about with our suggested return
45:12
to throat programs. Our goal through all of this is
45:15
not to get someone just to the point that they can return to
45:20
play, but we want them to be prepared to return to
45:25
competition and hit the ground running as if they've not missed
45:28
the beat. Part of that for us means we in
45:31
the return to throw program need to be able to create the
45:35
adaptations that Doctor Brolinson talks about and apply
45:39
that stimulus. And to us, there's no better way
45:42
to do that to build capacity, still being respectful of the
45:45
acute to chronic workload ceiling that we have to respect.
45:50
But in our program, we have 17 days that we are having pitchers
45:57
throw at Max intensity before we get to the point that we're
46:01
going to be ready to clear that person, even to throw a single
46:04
inning. And we think that better
46:06
positions pitchers to come back and be fully comfortable, not
46:12
just physiologically, but psychologically to meet the
46:15
demands required by competition. We probably should have said
46:18
this earlier. I don't want anyone to think
46:21
that everything that we're presenting here is purely
46:24
academic in nature. We've used the better parts of
46:28
all of these guidelines over 300 plus athletes over the last year
46:32
and a half and have had great success in using these criteria
46:38
and having people follow these programs.
46:40
And as Matt says, it's something that we will continue to iterate
46:43
on, but it's not as if we're just screen these up and then
46:47
figured out we would just suggest others follow them
46:49
without us having had lots of athletes go through them.
46:52
Now part of that dovetails into this concept of preparing
46:57
someone to throw. And This is why just if you
47:00
prepare someone, even if you say you're going to prepare someone
47:04
to throw a single inning, that doesn't mean they need to be
47:08
able to make 20 or 30 Max effort throws.
47:11
If you just think through for all of the baseball guys on this
47:15
webinar. If you're going to prepare a
47:17
pitcher to get ready to make a single twenty pitch outing, he's
47:23
likely going to long toss, he's likely going to do some pull
47:25
downs. He's then he's going to throw a
47:27
pin, then he's got pre game throwing.
47:29
So before you know it, that guy needs to be able to make 75 to
47:33
85 pitches that are essentially Max effort throws before he's
47:37
fully prepared to go into a game and just make throw 20 pitches.
47:44
So for us, if you look at this in the way that we built out our
47:47
program, that means over the course of our return to throw
47:50
programs still operating under a 1.3 acute to chronic workload,
47:55
we've got a guy making over 600 zone 10 throws.
48:00
We've seen other protocols that might have a guy make a total of
48:03
60 or 80 zone 10 throws over a period of five or six days and
48:09
all of a sudden declared that that guy's ready to return to
48:12
competition. All that means to us is he's
48:14
ready to return to play, but probably not going to be
48:17
tremendously confident in his ability to do so.
48:20
I mentioned this before, I'm not going to spend a whole lot of
48:24
time going through this chart, but understand that because we
48:28
have very specific criteria that we feel has to be met both
48:33
systemically and specific to the forearm, we know that not
48:36
everyone is going to meet that criteria.
48:39
So we've created return to throw programs that are customized
48:44
based on the actual performance and progression that our
48:48
athletes are able to make in the forearm.
48:51
Muscular chore, that's most important to protect the UCL.
48:55
And depending upon how players progress, that will determine
48:59
how aggressive we can be on the return to throw program.
49:03
And naturally then how long it will take them to get back to
49:07
the point that they're going to be good to throw an inning, 2
49:11
innings, 3 innings, begin return to throw any of those things.
49:15
So rather than just having a single cookie cutter approach,
49:18
we've at least started by bucketing people into at least
49:22
three different buckets. And we think we will just become
49:24
more customized in the process as we progress further.
49:29
Further, I'm sorry, one of the hot topics along this whole
49:32
concept of rehab is, is deload weeks.
49:35
I know Doctor Bowenson, I, I put this slide in because I know you
49:38
have some thoughts specifically about that.
49:40
So I figured I'd turn this back to you.
49:43
Yeah, I think that just putting pre programmed deload weeks and
49:46
they're just really physiologically doesn't make
49:48
sense. We talked about how, you know,
49:50
muscle tendon units have to be stressed in order for healing to
49:55
progress. So to just automatically throw
49:57
in a, in a deload week makes no sense to me.
50:00
Now, if you've got somebody that's having arm soreness or
50:03
some other difficulties than a deload may make sense.
50:06
But I think if you look at that chart that Darryl put up earlier
50:09
there, that one big dip was a deload week.
50:12
And again, from my, from my perspective, a deload week
50:14
doesn't make any sense because what we're trying to do, it is
50:17
again, progress the healing process.
50:20
And is, as I like to joke with my sports medicine fellas, you
50:23
know, healing is not a photosynthetic process.
50:26
This stuff doesn't get better just with air, sunlight and
50:28
water, right? The tissue needs to be loaded
50:31
and stressed in order for healing to progress.
50:33
So, so that's how so that's why I, I, I just don't like the idea
50:37
of a deload unless you're getting an athletes get into
50:40
problems having soreness, decreased velocities, things
50:44
like that. So Dylan, this is kind of I, I
50:47
think you can largely bring us home on this and then Matt will
50:50
close us out. But now we're back to kind of
50:52
the same chart in terms of our criteria.
50:55
Yeah. And I mentioned it briefly
50:57
earlier in the presentation, but we have our pre return to throw
51:00
criteria that we think sets the athlete up to be well supported
51:03
throughout that process. But by the time we get to return
51:06
to performance, there's largely not much the difference.
51:09
The difference we do want to see continued progression and our
51:12
global strength metrics, we want the athlete to absolutely be as
51:16
strong if not stronger than they were on a global scale.
51:19
Our Flex protesting, we have kind of our specific targets
51:21
there that we want to see athletes act compared to the
51:23
targets that the the Flex protein has developed.
51:27
And in terms of the shoulder, we just want to make sure that
51:29
we've maintained or continue to progress upon what our minimum
51:32
metrics were to even start the return to throw and to to play
51:36
off of this a little bit. And what Gunner was previously
51:39
talking about a big signal for AD load week, what it would be
51:42
if we start to see any decline in these variables.
51:45
So we believe that it's important that throughout this
51:46
entire process, you're consistently monitoring and
51:49
measuring many of these things. Doesn't have to be an obsessive
51:53
degree, but if you can get consistent signal data from the
51:56
athlete during this process, especially when you know you're
51:59
making jumps in intensity utilizing this data and
52:03
monitoring that can also help prescribe your delug leaks.
52:05
So. With that, I think we have one
52:07
more. Matt, you want to summarize what
52:11
we're trying to address here from a pure Brett, what we
52:14
believe is best practice. Yeah.
52:16
So I mean, I think a lot of this comes down to what Gunner
52:18
mentioned earlier about the specific adaptations to, to the
52:20
demands that we're asking on the, you know, on the medial
52:23
elbow. And so, you know, we're
52:24
identifying the equation that you brought up earlier, Daryl,
52:28
with regards to we know the force that the elbow is going to
52:31
have to withstand. We know what some of the static
52:33
stabilizers are. We don't know how to affect the
52:35
underlying ligament per SE yet, but we know that the overlying
52:39
flexure is something that's trainable, it's something that's
52:42
attackable, right. And so let's identify some of
52:45
these needs, identify the flexure pronator needs, identify
52:48
some of the other fundamental things that Dylan highlighted
52:51
with regards to strength metrics and and what we expect of the
52:54
athlete before they get out and ready to throw.
52:57
And so let's meet these thresholds as we're returning
52:59
them to throw as returning them to a higher level and hopefully
53:02
to performance. And I think utilizing velocity
53:05
based progressions and workload monitoring with or without the
53:08
use of a of a wearable as well, it's the key to progressively
53:12
loading the tissue because the tissue is going to respond to
53:14
load. All right.
53:15
We want to minimize these acute spikes and we want to be aware
53:17
of how the athletes feeling, how they're adapting, intervene when
53:21
needed and then understand how those D loads affect them,
53:24
right? So the D load effects that acute
53:26
to chronic workload ratio. And so we may have to make
53:28
further adaptations down line as we ramp them back up.
53:31
And so the goal is, you know, to build that underlying volume
53:34
that these athletes can then perform upon.
53:36
So I think that's the that's the kind of the key fundamentals of
53:39
the guidelines. And with that, guys, we're done.
53:43
We certainly thank you for your time.
53:45
We're we're just shy of an hour. There may be a time for a quick
53:48
question or two. But again, as I said, if you
53:51
have questions, put them in the chat.
53:53
We'll leave the channel open for a bit and happy to stay on if a
53:57
few of you want to stay on. But other than that, if
54:00
questions appear in the chat, we will go through it.
54:02
We will answer all of them and we will send out a document.
54:05
We will also send out the full narrative guidelines and the
54:09
attachments and encourage you to read through those at your
54:12
leisure. They'll provide all the
54:13
supporting information to everything that we've discussed
54:16
and contact information for any and all of us so that feel free
54:20
to reach out to us. In the end, as most people say,
54:23
it takes a village. We started this process, but we
54:26
don't feel like we're working in isolation.
54:28
We would love to continue to engage with all of you to
54:31
ultimately do what all of us want to do, which is to figure
54:34
out how to 1st keep guys healthy.
54:36
But for guys who get injured to figure out how to improve the
54:39
rehab process so that we can dramatically improve upon that
54:42
number to date, which again is somewhere in the neighborhood of
54:46
half to greater are really not making it back to prior levels
54:50
of performance in a way that we would want them to be able to
54:53
do. So I'm going to pull off the
54:56
share screen. Matt Dillon, Gunner, do you guys
54:59
have any closing thoughts before we might pull up a question or
55:02
two if people want to stay on? In closing, I think the whole
55:05
pursuit here is just to try and to try and facilitate the
55:08
process of, of constantly analyzing what we're doing, why
55:11
we're doing it and how we can do it better.
55:13
And, and again, I think this is very much a living document.
55:16
This is going to change. There's going to be stuff that
55:17
we got wrong. There's going to be stuff that
55:19
we got right. And I think it's just the
55:20
mindset of taking the next step, knowing that the rehab process
55:23
after UCL injury and UCL surgery has been sort of ripe for
55:28
improvement because historically we just haven't done as good of
55:32
a job as I think we've we've hoped.
55:34
And and that's, that's the goal here.
55:35
That's the goal here is to use some of the tools that we have
55:38
and be thoughtful about about progression and and loading and
55:41
adaptations or what we're seeking.
55:43
The other thing I add to that is my hope is that as we accumulate
55:47
additional data and like Matt says, some of this we're going
55:50
to get right, some are going to get wrong.
55:52
But I'd like to really think about this from a prevention
55:55
perspective. I would say my goal is to try to
55:57
keep you from going to see the surgeon.
55:59
So I think that we've got some ideas here in terms of
56:03
utilization of the device to help prevent injury.
56:06
So I think that's for me is kind of the Holy Grail with this
56:09
ultimately. Yep.
56:11
And my final piece would be, I think that we we continue to
56:14
build on all of the work that has existed prior.
56:16
And I think that's really the focus is that we're just trying
56:18
to make the next step. We know that it has been around
56:21
for many years and it's kind of been the status quo.
56:24
We think it's time. We think we have enough
56:25
experience and we have enough kind of anecdote to say that we
56:29
we can do things better. And here's our suggestions on
56:31
how we start to move that needle forward.
56:33
So with that, we are actually right at an hour.
56:36
We always promise to keep these to an hour.
56:38
We've not had any time obviously to handle questions.
56:42
We will handle every question that appears in the chat.
56:46
So get those. I don't want to speak for Dylan,
56:50
Matt and Doctor Rowenson, but I'm certainly happy to stay on
56:54
to address some questions if you guys wish to stay on.
56:57
So why don't we try to do that and if you need to drop, by all
57:01
means drop and then we'll address as we go.
57:04
Doctor Fury Burlinson, do you guys have a few more minutes or
57:06
do do you guys have clinic or what's your schedule?
57:10
I've got a few more and then I'm going to I'll I'll peel off the
57:12
clinic just shortly. All right, let me see then.
57:15
Doctor Fury, if there's one specific to you.
57:18
I think there was one I saw about.
57:21
I'm just not. I think we can touch on the
57:23
supination pronation bias. Which came, I'm sorry man, let's
57:27
ask the question. So the question was can you
57:29
elaborate on supination bias caveat?
57:32
Is this for those who are self-described pronators or
57:34
supinators? As APT professional and an
57:37
athlete without a reliable pitching coach, how do we
57:40
determine this? Yeah, I think a lot of, you
57:43
know, not everybody falls into these discrete buckets, but a
57:45
lot of throwers have a predisposition with regards to
57:50
some throwers have a natural cut and and that ends up being what
57:54
we consider a super nation bias, while other throwers are a
57:57
little more comfortable generating some arm side
58:00
movement. And that's where the pronation
58:01
bias comes in. And and you know, a lot of this
58:04
is subjective, which then manifests into objectivity
58:08
because they tend to have a predisposition to favor these
58:11
arm side Ron or favors either cutters, sweepers, sliders or
58:15
whatnot. But the, the point is we did
58:17
this, this study looking at how form position affected certain
58:21
elements of the, of the flexor. And we found that when you asked
58:25
players how they describe themselves, Hey, are you a
58:27
pronator? Are you a supinator?
58:28
There was there became a little bit of a division and people
58:31
that were naturally more comfortable with, with a
58:34
pronation bias. So with arm side run, when you
58:37
put them in supinated positions, they had some, some drop offs
58:40
and, and their overall flexor strength.
58:43
And so I think that's just indicates that certain throwers
58:45
are more comfortable doing certain things.
58:47
Now, is there a are they more comfortable that way because
58:49
their flexor works better in that position?
58:51
It's, you know, chicken to the egg.
58:52
I think you can get into that argument, but I think the point
58:55
is, is to treat every thrower differently, right?
58:57
And understand that, that we can measure some of these things
59:00
and, and we can prescribe them differently based off of their
59:03
underlying biases, their underlying, you know, phenotypes
59:06
and differences and try to again, smooth out some of these
59:10
big spikes. Because if somebody's got a
59:12
little bit decreased form flexor function in a supinated
59:15
position, if they're a natural pronator, then we just have to
59:17
think about what that volume means of the off speed pitches
59:20
that we're introducing, right, a little bit differently than the
59:22
contrary for a supinator. And so, so it, it maybe
59:26
introduces more questions and answers, but I think it just
59:28
shows that every throw is different and we're trying to
59:30
find ways to adapt it to the to the individual.
59:33
Bill, there was a specific question about use of BFR and
59:37
maybe can you expand a little bit upon your use of BFR and
59:42
where you find it useful and how you go about doing that?
59:45
Yeah. And there's a little bit of
59:46
controversy to some degree around when we can start using
59:49
VFR. Some people like to use it early
59:51
while swelling may be still present and some people
59:54
anecdotally kind of note that they they find it maybe helps
59:57
clear swelling regardless of when you use it.
59:59
Typically once you have full range of motion is when I will
1:00:02
start using. BFR, even if there's maybe a
1:00:04
little bit of puffiness, still still visible, but it's just my
1:00:07
way to get more out of the early stages of reloading.
1:00:10
When you're in that 5 to 8 week period, you're not utilizing
1:00:14
very heavy loads whatsoever and you're really just working into
1:00:18
re exposure for the tissue. You're not stimulating it enough
1:00:21
to actually stimulate any kind of hypertrophy or other
1:00:24
adaptation. So BFR is a nice way to kind of
1:00:27
enhance that because we do know that we can take those light
1:00:30
loads and get a metabolic effect to potentially stimulate some
1:00:33
hypertrophy or other things. So it's just one of the tools
1:00:36
that I like to incorporate really early on whenever I'm
1:00:39
reintroducing these lows to start to get this metabolic
1:00:43
effect and potentially some hypertrophy during a period of a
1:00:46
little bit of atrophy that they may have developed before and in
1:00:49
the early stages of surgery. Dylan, I think we kind of
1:00:52
addressed this, but it was related to a slide.
1:00:55
There was a question about thoughts on introducing
1:00:58
different pitches during catch play at submax.
1:01:00
Effort to regain some comfort with throwing them with grips
1:01:04
and the like. Yeah.
1:01:06
And and we mentioned it specifically in the context of
1:01:09
like doing it on the mound, there's there's absolutely room
1:01:12
for you to start introducing the change up the breaking ball,
1:01:15
whatever all your various grips in very light catch play.
1:01:19
But we kind of mentioned that you can do we recommend a usage
1:01:22
rate that's similar to their arsenal and that kind of fly to
1:01:25
their lower intensity throwing days as well.
1:01:27
It doesn't always have to be done at the Max intensity.
1:01:30
There's value in building confidence with higher frequency
1:01:33
of lower relative stimuli compared to what they're
1:01:36
currently at. So yeah, you can definitely
1:01:38
incorporate them early, often and get more touches on it
1:01:42
before you start asking them to really make significant
1:01:45
progressions as well. There's a question that I'll
1:01:48
start with and then obviously anyone else feel free to to
1:01:52
chime in on. But one of the questions was do
1:01:55
we have any other data besides our own subjective survey data
1:02:00
to validate thoughts on how many number of throws equal a single
1:02:03
throw. And the short answer is no, we
1:02:06
don't have it because we've we've looked there is no
1:02:10
objective research the the IMU or the the throw valuation data,
1:02:17
if you will, that much of the industry is operated on is based
1:02:21
on the IMU data that first came out of MODIS now pulse and their
1:02:26
valuation method is actually based on a NASA bone density
1:02:30
study. And that's it.
1:02:32
There's no question that those who are skilled in using that
1:02:35
device can do a wonderful job getting the data off of it and
1:02:41
then making changes to bucket how many got how many throws
1:02:46
you're going to let someone make in a zone 3A, zone 4, zone 5.
1:02:51
But if you ask a pitcher whether or not quote a zone 5 throw and
1:02:56
the number of throws that they are assigned to make that are
1:03:00
supposed to equal a single Max effort throw, if that actually
1:03:04
represents their reality, they will tell you not even close.
1:03:11
So what we've tried to do was build the model that we thought
1:03:14
was more representative to match what a large population of
1:03:18
pitchers told us to be the case. And as I said, that's something
1:03:22
that I think is a wonderful topic for further research
1:03:25
because the harsh reality is, is we really don't know how the
1:03:32
relationship of sub Max throws works to build capacity to throw
1:03:37
at high intent. One of our contributors, Casey
1:03:40
Mulholland talks about the concept always of looking at
1:03:44
marathon running when he's explaining the concept of acute
1:03:47
to chronic workload ratios. And we would use the analogy and
1:03:51
say if Usain Bolt was training to win an Olympic medal, there's
1:03:56
no amount of mile runs or jogging, I don't care how long
1:04:00
he jogs, that's going to prepare him for a Max effort Sprint.
1:04:05
So again, that's that said principle.
1:04:07
And what we really know is we need to be able, if we want guys
1:04:11
to be prepared to throw at Max intensity and build up the
1:04:15
tissue capacity to handle it, we need to prepare them to throw at
1:04:19
Max intensity. And we frame that when you look
1:04:23
at, if you look at our guidelines, when we start
1:04:25
bracketing how we assign return, how we assign volume across
1:04:30
different zones, we're very, very specific about the amount
1:04:34
of throws we think need to be made to make sure that we create
1:04:38
a nice progressive accumulation to get guys where we really want
1:04:42
them to be, which is handle Max effort throwing.
1:04:44
Gunner, Dylan, Matt, if you think I missed anything on that,
1:04:47
by all means chime in. I.
1:04:49
Think you're good. So there's a question in here as
1:04:51
well from thoughts on utilization of a throwing sock
1:04:54
prior to first throws and and during D load periods.
1:04:58
And I want to kind of expand on that question a little bit as
1:05:00
well. So throwing sock is just like a
1:05:01
it's, it's like a myth that you put on and the ball just like
1:05:05
releases and goes into a sock essentially.
1:05:08
So you kind of fake throw it, if you will.
1:05:10
You don't see it go anywhere. Yeah, it could be a tool.
1:05:12
It could definitely be utilized as a way to reintroduce throwing
1:05:15
in a very low threat environment.
1:05:17
When you're working, especially if you have the opportunity to
1:05:20
work one, one-on-one with an athlete, those first couple of
1:05:23
days or weeks of the return to throw can sometimes be anxiety
1:05:26
ridden and they get really concerned about their mechanics
1:05:29
and all of these other things. So, yeah, especially in the late
1:05:33
stages of rehab or right before you start throwing, doing things
1:05:35
that maybe reduce the pressure on the athlete is good.
1:05:40
And then utilizing deload periods, yeah, it could
1:05:42
definitely be a tool there. Deload periods in general, the
1:05:45
way that I think about it is I just want to remove like my top
1:05:47
20% of peak stresses that they're experiencing, wherever
1:05:51
that may be in the progression. And I want to reduce it down and
1:05:55
then rebuild that back up. And then to expand on that
1:05:58
question a little bit, to some degree, it's, it's speaking to
1:06:00
the utilization of various constraints and return to throw.
1:06:05
Not every throw needs to be made with a baseball.
1:06:07
Every throw you can utilize overload balls, underload balls,
1:06:11
footballs, other things. And, and the more experience
1:06:13
that somebody gets with return to throw, especially if they do
1:06:16
this a lot, the more comfortable they'll be breaking away from
1:06:19
these guidelines a little bit overtime and modifying them to
1:06:22
what they like to do and what what fits.
1:06:24
Yeah, I think there's room for this just in the guidelines that
1:06:27
we're providing. It's just kind of assuming we're
1:06:29
going to utilize a consistent standard baseball and velocity
1:06:33
progression, and then more skilled practitioners can start
1:06:35
to deviate as they see fit. Dylan, I think you brought
1:06:38
something up earlier in the presentation about the the
1:06:42
reintroduction to value slowing in the media elbow and sort of
1:06:44
the various phases. The whole goal of demonstrating
1:06:47
that the elbow is if you know, to impose these stresses that we
1:06:51
know it's going to have to withstand, But at the same time,
1:06:53
psychologically, you're also taking the athlete on a journey
1:06:56
too as well, right, With regards to experiencing stress over the
1:07:00
medial elbow, with regards to rebuilding the strength to where
1:07:04
we get to the point where we use other implements, Plios other
1:07:07
things to demonstrate like, Hey, we're ready.
1:07:10
And I can tell you that, you know, as from the surgical side,
1:07:13
but also as a, as a patient, you know, I had UCL surgery when I
1:07:15
was in college. And I can, I can distinctly
1:07:18
remember the time standing on the field staring at a baseball
1:07:20
in my hand on the on day one and being like, I wonder how this is
1:07:25
going to go in my head, right? There's a psychological aspect
1:07:29
of return. There's a psychological aspect
1:07:30
of recovery. And you really shouldn't feel
1:07:32
that. You shouldn't feel like, I
1:07:33
wonder how this is gonna happen. You should have proven to
1:07:36
yourself all along the way that I am ready to withstand this.
1:07:40
I have built this capacity, I've built this resilience.
1:07:43
And now I'm ready for this moment, right.
1:07:45
And I think that's, that's part of what you delineated very
1:07:48
clearly earlier. The the whole idea is, is just
1:07:52
showing the elbow they can withstand the things that's
1:07:55
going to be expected to to do. Yeah, and I always harken back
1:07:58
to our friends in the ACL field because they're so much more,
1:08:00
you know, it's it's much broader, much more deeply
1:08:02
researched. And you'll never see a soccer
1:08:05
player going back to the field at a high level when they
1:08:07
haven't done a ton of high velocity change of direction,
1:08:11
work exposure, chaotic environment stuff because that
1:08:14
the entire purpose is to re expose it was the stress and
1:08:18
we're improve the psychological aspect and makes them make them
1:08:21
feel confident. And we don't really do that in
1:08:22
baseball. We just kind of like you said,
1:08:24
hand them the ball and say good luck.
1:08:26
There's one question and maybe unless there's one that you guys
1:08:30
feel like we should address in addition, maybe we can take this
1:08:33
one and stop and then just address the rest offline.
1:08:37
But the question had to do with someone who said that they they
1:08:40
don't have access to an IMU. So what's the best way to go
1:08:44
about progressing guys through rehab if they don't have access
1:08:48
to an IMU? Should they use RPE?
1:08:49
They are, how should they use it?
1:08:51
And I think our response to that, I think Dylan addressed
1:08:54
that in the presentation, was that absent an IMU, we feel like
1:08:58
velocity by far is the single best modality to use to progress
1:09:04
someone because it has the highest and strongest
1:09:07
correlation to elbow valgus torque throughout the throat.
1:09:12
So it's hard for us to think that someone who's going through
1:09:16
rehab from any sort of UCL or flexor injury would not at least
1:09:21
have access to buying a pocket radar.
1:09:24
And what we would suggest, and that's completely delineated in
1:09:28
our return to throw protocols is zone progressions, which for us
1:09:33
would be velocity ranges that we think someone should throw at.
1:09:38
And our suggestion to anyone managing someone's return to
1:09:42
throw is at a minimum, if you do not have an IMU, just get a
1:09:46
pocket radar and make sure that you define the throwing ranges
1:09:51
that you would expect someone to throw at.
1:09:54
And that will give both you and the athlete a very, very good
1:09:58
indication as to whether or not the athlete is progressing
1:10:01
according to schedule. And with that, then you can
1:10:04
start to prepare. You can again to compare how the
1:10:09
athletes progressing on what matters to him most with
1:10:12
throwing to the objective data that we would expect the athlete
1:10:16
to be hitting to see whether or not plateaus are occurring
1:10:19
either in his strength, his rate of force development, power,
1:10:24
endurance, any of the metrics that we now have the ability
1:10:27
with Flexburg Grips technology to objectively measure don't
1:10:31
anything to add to that. If not, then let's just wrap it
1:10:34
up, no? The only thing I would add is I
1:10:36
don't want to also over emphasize the zones and things
1:10:39
like that like but we do believe that the vast majority of the
1:10:42
throws that you make should fall within the zones.
1:10:44
But if you break that on one or two throws, it's not the end of
1:10:47
the world. The motto isn't destroyed.
1:10:48
You don't have to scold the athlete, The athlete doesn't
1:10:50
have to feel ashamed or whatever.
1:10:51
The goal is to provide a progressive but relatively
1:10:57
consistent range for the athlete to operate within during
1:11:00
whatever throwing session that they may be working through and
1:11:03
just to minimize the the likelihood that they're going to
1:11:06
begin to exceed the desired intensity progression that we
1:11:09
want them to. So it's it's not the end all be
1:11:12
all, but it is our just most consistent and reliable tool.
1:11:16
So what I'm going to do and I'll Dylan, I'll ask you to do the
1:11:19
same. Obviously we'll address
1:11:21
everyone's questions, as I said, online, but if you, Dylan, maybe
1:11:25
can just put your e-mail in the chat so that everyone has that
1:11:30
directly. So if anyone wants to reach out
1:11:31
to you directly, they have a way to access you.
1:11:35
They'll see it in the guidelines, but I wanted to just
1:11:37
put that in in make that available now.
1:11:40
I can type yours in Dylan if you don't have.
1:11:42
Access and then somebody asked if they have to buy anything.
1:11:45
Right now, though, I believe everything we're sending out is
1:11:47
everything. Every everything is going to
1:11:50
your e-mail and then feel free to please ask a lot of questions
1:11:54
based off of those emails that you get with after you've had
1:11:57
time to sift through them. Feel free to offer your critique
1:12:00
as well. We we are open to the feedback
1:12:02
or challenges to what we have presented.
1:12:06
Wonderful to everyone. Thanks so much for your time and
1:12:10
for joining us. And we look forward to further
1:12:13
dialogue. Great seeing you.
1:12:15
Thanks as well. Thank you.