Elbow Pain and the Pitcher – The Road to Tommy John Surgery


  • Elbow pain is quite common in pitchers, and can be caused by an elbow problem or a shoulder problem.
  • ASMI recommends pitching less, and taking adequate time off!
  • Certain exercises add hidden stress to this area, and can slow the healing process in the off-season, or speed up the occurrence of damage in season.
  • Since the shoulder is connected to the spine, and many muscles going to the shoulder come from the neck and mid back (even the low back!), we’d better look there too!

Background and elbow anatomy

Elbow pain plagues young athletes, and professional players as well. One of the main players in this surgery epidemic is the UCL (Ulnar collateral ligament) of the elbow. The throwing motion causes stress to this area, but we’ll explore some other ways to add stress as well. With that in mind, you’ll have some ideas of how to LIMIT stress to this ligament!

Ulnar collateral ligament of the elbow
Ulnar collateral ligament damage may require Tommy John surgery.

The ulnar collateral ligament is found on the inside of the elbow and connects the ulna (bone on the inside/medial side of the forearm) to the humerus (upper arm). It is stressed as the forearm is moved laterally (away from the body) while the humerus (upper arm) stays in place (radial deviation). In the throwing motion, specifically max effort throws, the forearm lags behind the upper arm as the pitchers accelerates the arm forward. This creates “lay-back” or the “whip” action we are looking for in pitchers. Over time, this area gets stressed quite a bit, and can lead to injury. That’s why we try to stick to ASMI (American Sports Medicine Institute) recommendations of less pitching at ESA!

ASMI recommendation summary:

  • Less than 100 innings pitched per year
  • Avoid pitching for more than one team at a time
  • Master the throwing motion, then pitching mechanics, then the fastball, and the changeup (if you’ve worked with me, you’ve heard me say this!)
  • No competitive pitching for 4 months each year, and no overhead throwing for a minimum of 2 months (more risk) and hopefully 3 or 4 months (less risk)!
  • Rest adequately, and look for signs of fatigue on the mound (loss of control or velocity = time to rest!)
  • Eat well and hydrate. Would you put cheap fuel in a Ferrari? I didn’t think so. Do better!

Training Considerations

Strength training needs to follow the SAID principle (specific adaptations to imposed demands), so a baseball player shouldn’t train like a football player. It makes no sense! Baseball players can lift heavy, but they need to master proper form first. Basics like the goblet squat are easy, but can be challenging. Hip thrusts and kettlebell swings simulate a deadlift while we teach proper form, and can be loaded significantly.

When it comes to upper body movements, pressing is fine with some modifications. Many people are shocked when we floor press, or don’t do a full range of motion bench press. That’s to prevent shoulder issues, but it makes sense to add it while I’m on a roll! Since we’re looking for movement of the shoulder blade, we focus heavily on push ups and landmine variations. Why? To make sure the shoulder is working correctly, and to hopefully prevent further insult to the shoulder AND the elbow.

As for elbow specific work, general forearm strengthening that limits stress to the UCL is key. Keeping the forearm in line with the upper arm is crucial. It’s not really possible, because our forearms generally point outward from our elbow, but we need to limit the insult. So losing a bicep curl (not that I regularly program them in, but you young guys are going to do them behind my back anyway!) out to the side is a no-no. Pull-ups in season tend to irritate the elbow for a different reason in many cases, but any insult or pain may cause you to change how you move (compensation). Again, S.A.I.D. Keep it simple, and make sure you know what you’re doing.

Better yet (warning: shameless plug), get someone who knows what they’re doing to set up your program!

When it comes to lower body training, you know I love me some front squats, but many pitchers struggle with the proper bar position and may end up stressing this area in the weight room. A cross-arm grip helps with this, as does a safety squat bar. This grip issue is part of the reason I don’t like cleans for pitchers. The catch is just too difficult to teach in an athletic population that usually starts training a bit late in their youth career.  There are other options to teach an explosive hinge, like kettlebell swings, pull-throughs, high pulls, box jumps, and medicine ball throws.

Programming consideration: as we get back into the swing of things, weightlifting needs to decrease. Medicine ball reps drop, since we get rotational training from swinging and throwing. But, that doesn’t mean it stops. Training programs just need to be modified once in a while to ensure we’re not overloading or underloading tissues.

Performance chiropractic and soft tissue work

If you didn’t know I’m a doctor, well here it is: I am! My passion is getting athletes back on the field, and ensuring they can play at their peak, while limiting damage to crucial areas.

Adjustments to the spine can ensure you get proper spine extension, which helps the shoulder get where it needs to be. Without that, you need to compensate, and will overuse the shoulder or the elbow.

Soft tissue methods aim to speed recovery. Clinically, I use them for pain relief and gaining range of motion. On the performance side, I use them to increase range of motion so we can strengthen an area. These reasons are likely why the top trainer to professional baseball players recommends AT LEAST monthly soft tissue treatments.

Most importantly, you need to get an assessment of your movement. It’s why I combine the functional movement screen (FMS) with range of motion and shoulder blade tests. We need to know your anatomy and biomechanics BEFORE we throw to ensure we are using all of the right methods to improve your game.

Wrap up

If you have pain, schedule a clinical consultation. If you don’t schedule a performance eval (FMS+). It’s that simple. Yes, I’m selling something here. But, so is that surgeon. And (this is a huge and), the top surgeon for pitching elbows would likely agree with everything I said here. I’m not doing this to better me, I’m do what I do to help you. Period.



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