Re-envisioning Throwing Programs for Baseball Pitchers: A Case Report and Literature Review PDF Free Download
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©The Internet Journal of Allied Health Sciences and Practice, 2025
Dedicated to allied health professional practice and education
Vol. 23 No. 1 ISSN 1540-580X
Re-envisioning Throwing Programs for Baseball Pitchers: A Case Report and
Literature Review
Andrew Cage1
Alexander P. Jacobsen1
Clayton Hodges1
Cassandra Rasmussen1
Jon-Michael Cline2
Brandon J. Warner3
Lynzi K. Warner4
Laurel Trail1
Ryan Johnson5
Matt Schimpf6
Pauline Skowron1
Robert French1
Derek Lege1
Nathan Campbell1
1. University of Texas
2. Azalea Orthopedics
3. Grand Canyon University
4. Creighton University
5. Angelo State University
6. APEC Fitness Center
United States
ABSTRACT
This case report follows the injury presentation and return to pitching of two NCAA Division II baseball pitchers. A literature review
is provided to detail the current prevalence and epidemiology related to injuries to the throwing arm of pitchers. The review also
outlines current procedures for returning a baseball pitcher to pitching from the mound. The authors discuss key concepts related
to progressing previously injured pitchers back to pitching from the mound, while using the two cases presented as exemplars for
using the objective, goal oriented, and adaptable interval throwing program developed at the pitchers’ university.
Keywords: SLAP tear, ulnar collateral ligament, interval throwing programs, GIRD
RE-ENVISIONING THROWING PROGRAMS FOR BASEBALL PITCHERS 1
©The Internet Journal of Allied Health Sciences and Practice, 2025
INTRODUCTION
Baseball pitching exposes the glenohumeral and humeroulnar joints to large forces due to the nature of overhead throwing.1 During
maximal exertion, these forces can exceed 1.5 times the body weight of the pitcher during the deceleration phase of throwing.2
The forces experienced at the glenohumeral joint have been further quantified, as the shoulder moves at angular velocities up in
excess of 7,250o/s during throwing.1,3,4. Throwing is an aggressive physical activity, with levels of muscle activity often surpassing
maximal volitional isometric contraction abilities in competitive and elite settings.5. As a result of the repetitive nature of baseball,
the shoulder and elbow undergo these forces regularly during practices, games, seasons, and over the course of a player’s career.6
This has led to shoulder and elbow injuries becoming a primary concern among competitive baseball pitchers.
Epidemiological studies have shown the issues created by the repetitive nature of overhead throwing with regards to injury rates
at the shoulder and elbow in baseball players.7 Indeed, shoulder (21.2%) and elbow (15.5%) injuries represent the most common
musculoskeletal injuries in collegiate baseball.8 In professional baseball, shoulder injuries account for 27.8% of all days spent on
the injured/disabled list.9 In the professional setting, upper extremity injuries appear to affect pitchers more regularly than position
players, with pitchers remaining on the disabled list an average of 20.1 days more than position players.10 Even at levels not
considered to be elite, shoulder injuries represent 34.2% of all injuries in high school baseball pitchers.11
These injuries to the shoulder and elbow can create a number of issues for baseball pitchers including time lost playing baseball.12
When considered from the perspective of elite college and professional levels, this lost time can have financial implications.13
Whether from salary, scholarship, or other forms of compensation, injuries have the potential to negatively impact the finances of
baseball players. Between the risk of lost compensation and time played, combined with the increasing number of shoulder and
elbow injuries being experienced in baseball, preventing injuries has become a major goal amongst sports medicine healthcare
professionals, coaching staffs, and athletes.
Several predictors for developing shoulder and elbow injuries have been identified in competitive baseball players. These factors
include: pitching while fatigued, pitching year round, glenohumeral internal rotation deficit (GIRD), active internal and external
rotation at the glenohumeral joint, scapular dyskinesis, shoulder external rotation to internal rotation strength imbalance, number
of pitches thrown during the season, and pitching past recommended age-specific pitch counts.14-22 As more predictors have been
identified, sports medicine healthcare professionals and coaching staffs have taken steps to decrease the prevalence of shoulder
and elbow injuries among baseball pitchers.23 Efforts included pitch counts, workload management, and pre- and post-outing arm
care programs have been implemented at multiple leagues across various levels.23 However, to date the prevalence of shoulder
and elbow injuries among baseball players continues to rise.24-30 Given the lack of success of current interventions, there is a need
for a better understanding of the most common pathologies that affect the shoulder and elbow of competitive baseball players. It
is important to understand best practices in treatment and rehabilitation of shoulder and elbow injuries in competitive baseball
pitchers with the intention of returning to the previous or higher level of competition. Therefore, the purpose of this article is to
present a review of the current literature, along with a case report of two collegiate baseball pitchers who returned to pitching after
injury using a velocity-based return to throwing program that the patients were involved in creating as opposed to traditional return
to throwing programs which rely on distance based prescription that does not incorporate individualization.
OVERHEAD THROWING PATHOLOGIES
Two of the most common musculoskeletal injuries affecting baseball pitchers are superior labrum anterior to posterior (SLAP)
lesions, and ulnar collateral ligament (UCL) sprains.25,30 As previously mentioned, these injuries have the potential to cost injured
pitchers practice and playing time, as well as compensation.13 This has led clinicians and researchers to attempt to determine
underlying factors that predispose pitchers to these injuries, including scapula kinematics. Determining the most common
predictors is a potential method of identifying areas to apply preventative interventions. Additionally, knowledge of the
biomechanics of pitching is valuable for understanding the demands being placed on pitchers and the injury predictors they are
exposed to. Table 1 provides a summary of the phases of pitching and the biomechanic components of the action.31 Therefore, a
thorough understanding of these injuries and how they are treated is valuable.
Table 1. Phases of Pitching31
Phase
Explanation
Wind-up
● Begins when pitcher is in a static position facing the batter with both feet on the pitching
rubber.
● Hands are together with ball in glove.
● Center of gravity is stabilized.
● Finishes when the lead knee reaches maximum height and the pitcher begins to remove the
ball from the glove.
RE-ENVISIONING THROWING PROGRAMS FOR BASEBALL PITCHERS 2
©The Internet Journal of Allied Health Sciences and Practice, 2025
Phase
Explanation
Stride (Early
Cocking)
● Begins when the lead knee reaches maximum height.
● Lead leg knee and hip extensors eccentrically contract to control the limb to foot contact.
○ Gluteus maximus, gluteus minimis, piriformis, and obturator internus
● Stance leg hip internal rotators concentrically contract.
○ Tensor fascia latae, gluteus medius, hamstrings
● Pelvis rotates 400-700o/second.
● Shoulder and thoracic spine remain in a relatively closed position.
● Scapula of the throwing shoulder begins to rotate upward and retract.
● Glenohumeral joint of the throwing shoulder begins to abduct.
● Rotator cuff and scapular stabilizer contract to provide stability.
● Elbow reaches a flexion angle between 80-100o .
● Glenohumeral joint begins to externally rotate.
● Center of gravity is lowered and accelerated toward home plate.
● Finishes when the lead foot contacts the ground.
Late Cocking
● Begins when lead foot contacts the ground.
● The trunk begins to rotate toward home plate.
○ Concentric contraction of lead leg side internal oblique and erector spinae
○ Eccentric contraction of the back leg side external oblique
● Lead leg knee moves into extension concurrently with trunk rotation.
● Lumbopelvic region and hip begin to stabilize the lead leg.
○ Gluteus maximus
○ Gluteus minimus
○ Gluteus medius
● Stride leg gluteus medius contracts to internally rotate the hip.
● Throwing shoulder scapula retracts further.
● Throwing shoulder moves to between 90o and 110o of abduction.
● Throwing shoulder moves to between 50o and 185o of external rotation.
● Triceps brachii eccentrically contracts to prevent excess elbow flexion.
● Finishes when the glenohumeral joint of the throwing shoulder reaches maximum external
rotation.
Acceleration
● Begins when the glenohumeral joint of the throwing shoulder reaches maximum external
rotation.
● Trunk is stabilized as both the lead and stance feet are in contact with the ground to begin
this phase.
● Trunk flexes to between 32o to 55o.
● Scapula begins to protract.
○ Concentric contraction of serratus anterior
● Throwing shoulder glenohumeral joint begins to internally rotate to 90o.
○ Concentric contraction of latissimus dorsi and pectoralis major
○ Eccentric contraction of supraspinatus, infraspinatus, and teres minor
● Elbow extends to 25o
● Finishes when the ball is released.
Deceleration (Follow
Through)
● Begins when the ball is released.
● Stance leg foot leaves the ground.
● Trunk rotates over the lead leg as the knee moves into extension.
● Lead leg hip internal rotators concentrically contract to bring the pitcher to a balanced fielding
position.
● Supraspinatus, infraspinatus, teres minor, and deltoid eccentrically contract to control
deceleration of the glenohumeral joint and stabilize the humeral head.
● Elbow reaches or nears the end range of extension.
● Finishes with maximum throwing shoulder glenohumeral internal rotation and 35o of
glenohumeral horizontal adduction.
RE-ENVISIONING THROWING PROGRAMS FOR BASEBALL PITCHERS 3
©The Internet Journal of Allied Health Sciences and Practice, 2025
Superior Labrum Anterior to Posterior Lesions
The glenoid labrum serves as one of the primary stabilizers for the glenohumeral joint, and injuries to this structure can lead to a
number of issues for overhead athletes.32 Andrews et al26 originally described SLAP tears in 1985, with Snyder et al27 describing
the detachment of the superior portion of the glenohumeral labrum from the glenoid rim with or without involvement of the long
head of the biceps brachii in 1990.While there are more common glenohumeral labrum pathologies, the presence of a SLAP lesion
in baseball players undergoing arthroscopy is as high as 26%.28 The prevalence of SLAP tears appears to be even higher in the
competitive athlete population, with SLAP lesions identified in throwing athletes at the high school, college, and professional levels
undergoing glenohumeral joint arthroscopy in 83%-91% of case.26,29
While traumatic SLAP lesions can occur, the majority of these lesions are atraumatic as a result of overuse.32 There are two
prevailing theories as to the mechanisms of throwing a baseball that result in the microtrauma to the superior labrum and biceps
brachii origin.32 One hypothesis is that the eccentric load placed on the biceps brachii while the elbow extends during arm
deceleration at follow through can result in tissue failure at the superior labrum and long head of the biceps brachii tendon.26,28
This would suggest that the majority of traumatic SLAP lesions occur during the deceleration and follow through phases of throwing.
A second theory proposed the “peel-back” mechanism, in which torsional force on the biceps brachii origin at maximal abduction
and external rotation results in tissue failure at the superior labrum and long head of the biceps brachii tendon.33 In all likelihood,
both mechanisms likely account for a portion of the SLAP lesions.34
The majority of SLAP repairs in competitive athletes are managed conservatively unless symptoms prove too problematic.35-37 The
rationale behind this course of treatment is multifactorial. Namely, providers seek to try to avoid surgery due to financial implications
and loss of time. Additionally, reports of return to previous level of competition have suggested varied results. The rate of return to
previous levels of competition has been reported as 54.2%-84.1%.35-37 In cases where SLAP repair patients were unable to return
to their previous level of competition, patients reported decreased strength and decreased range of motion as the largest limiting
factors. This varied rate of successful outcomes makes conservative treatment as a frontline intervention even more attractive.
Ulnar Collateral Ligament Sprains
Within the elbow, the UCL serves as the primary restraint to valgus stress for the humeroulnar joint.30 Structural failure of the UCL
is more common among throwing athletes, particularly baseball pitchers.30 These injuries can occur as a result of either gradual
degradation of ligament tissue or from acute ruptures.30 Whatever the case, when UCL injuries do occur, they result in significant
loss of time from practice and competition.30 Conservative management involving rest and therapeutic exercise often results in a
time loss of three to four months for pitchers.30 On average, most athletes return to full competition within 12 to 15 months following
UCL reconstruction.30 However, professional pitchers generally require 15 to 18 months to be able to pitch at their previous level.30
Repair of the damaged UCL has become a more popular surgery using collagen-dipped suture tape to provide structural support
to the existing ligamentous structure, more commonly known as a UCL repair with an internal brace.30 Repair of the UCL has also
been performed to bolster reconstruction surgeries, with the goal of providing more stability to the compromised structure.30 The
short term initial results that have been published have shown promise, with subjects exhibiting less gapping at the humeroulnar
joint post surgery30 Despite this popularity, long-term results have yet to establish the efficacy of UCL repair, particularly among
elite level pitchers.30
While repair of the UCL is a viable option for some partial sprains ligament, more severe sprains and sprains in of the middle and
distal aspects of the ligament often result in the need for UCL reconstruction.30 Reconstruction of the UCL is often a more invasive
technique, consisting of debridement of damaged ligament tissue and the grafting of an artificial ligament.30 This ligament is often
made from the palmaris longus tendon, or a hamstring tendon from a cadaver.30 In addition to being a more involved and invasive
surgical intervention, UCL reconstruction requires a longer recovery time than UCL repair. Patients undergoing UCL repair are
often able to return to sport within three to four months, while UCL reconstruction patients require at least 12 to 15 months to return
to sport.30 Due in part to the lack long-term patient outcomes for UCL repairs, UCL reconstruction is currently the gold standard for
operative management of a complete UCL rupture.30 Initial success rates of these surgeries were relatively low, with 63%-70% of
athletes returning to their previous level of competition following UCL reconstruction.38,39 As methodology, expertise, and research
have progressed, success rates for UCL reconstruction have improved, with 81%-93% of patients returning to their previous level
of competition.40-42 These success rates for UCL reconstruction surgery are of particular concern, as patients undergoing revision
of a UCL reconstruction often have less optimal outcomes than patients who have undergone primary reconstruction.43 While the
currently available literature on success rates of revision UCL reconstruction surgery is sparse, one case series reported a 55%
return to previous level among professional baseball players of competition rate following this surgery.44 Even with this improved
efficacy, there remains support for finding alternative interventions to UCL reconstruction given the amount of time lost between
surgery and rehabilitation.
RE-ENVISIONING THROWING PROGRAMS FOR BASEBALL PITCHERS 4
©The Internet Journal of Allied Health Sciences and Practice, 2025
Current literature is in general agreement that low to medium grade UCL sprains are usually viable candidates for conservative
management with rest and a gradual return to activity.30,45-51 Location of these sprains is important when identifying patients who
would be good candidates for conservative management. Previous studies have shown that patients who experience injury to the
proximal attachment site of the UCL had better non-surgical outcomes than patients with an injury to the distal attachment site.49
This disparity in successful non-surgical management is likely due in part to the richer vascular supply of the proximal UCL
attachment site.51 With better blood flow, UCL injuries to the proximal attachment site would likely have a better opportunity to heal
without surgical intervention.
Another non-surgical intervention for UCL sprains that has grown in popularity is platelet rich plasma (PRP) injection.30, 49-51 Platelet
rich plasma is derived by performing a blood draw on the patient being treated and then spinning the blood sample in a centrifuge.52
After the blood sample is separated out via the centrifuge, the layer of PRP is removed and injected into the treatment site.52 The
goal of a PRP injections is to serve as an adjunct treatment to rest and rehabilitation by introducing autologous platelet growth
factors into the treatment site with the intent of stimulating cell differentiation, proliferation and angiogenesis.53-55 If successful, PRP
injections theoretically expedite and improve the healing of injuries.52-56 To date, studies assessing the use of PRP injection to treat
partial UCL tears has consisted largely of case series.49,50. These studies have shown promising results.45 A critically appraised
topic manuscript on the use of PRP to treat partial UCL to enhance healing showed similar promise, but authors have been careful
to note that current recommendations for PRP injection to treat UCL sprains is only level 4 evidence.56
As previously mentioned, while conservative interventions require less time lost when successful, appropriate candidate selection
is crucial to optimal outcomes.49,50,57 Stage of season, stage of career, location of sprain, and severity of sprain are all important
factors when advising a patient on the best course of management for a UCL sprain.49,50,57 A complete rupture or partial tear at the
distal attachment site of the UCL will have the best patient rated outcomes with UCL reconstruction.50,57 Conversely, partial tears
of the UCL at the proximal attachment site may respond well to rest and rehabilitation augmented by PRP injection.49,50,57
Additionally, individuals who do not intend to continue their sport beyond the time it would take to recover from UCL reconstruction
and who do not experience symptoms with activities of daily living may be able to forego surgical intervention even with a complete
rupture.50 Ultimately, all of these factors need to be considered when consulting with a patient who has experienced a UCL injury.
Scapular Dyskinesis
While not as acutely detrimental to playing time as SLAP lesions and UCL tears, scapular dyskinesis can be problematic for
baseball players, particularly pitchers. The scapula plays a pivotal role in the mechanics involved in accomplishing the task of
repetitive, high load, and rapid overhead throwing.58 These roles are outlined in Table 2.
Table 2. Roles of the Scapula in Overhead Throwing
Role
Explanation
Dynamic stability allowing for
distribution of force throughout the
kinetic chain.58
● Effective stabilization at the scapula allows for more efficient force
distribution from the core and legs to the hand during the acceleration
phase of throwing.59
● During the deceleration phase of the throwing, a properly stabilized scapula
provides 40% of the resistance to eccentric loads experienced from the
deceleration phase through the follow through phase of throwing.60
Provide a stable base to allow for
optimum efficiency during shoulder
muscle activation and force
distribution.58
● A stabilized and retracted scapula is needed to allow for maximum arm
flexion, abduction, and external rotation force generation in both pathologic
and nonpathological overhead athletes.61,62
Dynamic 3-dimensional motion.12
● The scapula moves along the posterior rib cage in three distinct motions.63
○ Internal and external rotation about a superior axis
○ Upward and downward rotation in the scapular plane
○ Anterior and posterior tilt about a horizontal axis.
● Movement of the scapula along the posterior rib cage occurs in conjunction
with humeral motion to create scapulohumeral rhythm.58
○ Scapulohumeral rhythm is the result of the motions and positions used
to maximize the compressive mechanisms that reduce shear force at
the glenohumeral joint and the surrounding structures.64
○ The more precise these motions and positions are, the less internal
impingement and shear forces are experienced by the labrum and
surrounding structures.65
RE-ENVISIONING THROWING PROGRAMS FOR BASEBALL PITCHERS 5
©The Internet Journal of Allied Health Sciences and Practice, 2025
Role
Explanation
○ The more precise these motions and positions are, the better the
labrum functions to distribute loads evenly.66
○ Efficient scapula motion allows the acromion to move upward and
posteriorly, increasing the subacromial space and decreasing external
impingement and rotator cuff tendinopathy.67-69
During most overhead throwing motions, a healthy scapula will go through a predetermined sequence of motions.58 As the humerus
moves into terminal abduction, specifically during the late cocking phase of pitching, the scapula rotates upward, tilts posteriorly,
and externally rotates.70 Once the humerus begins to externally rotate during the cocking phase of throwing, the scapula continues
to rotate upward, externally rotate, and posteriorly tilt into maximum scapular retraction.71 When stride foot contact occurs, the
scapula begins to tilt anteriorly.72,73 The scapula continues to anteriorly tilt and begins to internally rotate as the arm progresses to
the ball release portion of the deceleration phase.58 During the rest of the deceleration phase, the humerus moves into maximum
internally rotation while the scapula begins to rotate downward.70 As throw is concluded, the scapula is in an anteriorly tilted,
internally rotated, and downwardly rotated position, representing the opposite end range of motion from terminal humeral external
rotation.73 To achieve these different motions and positions, there are a number of muscles involved. Muscular activity relative to
the scapula during throwing is detailed in Table 3.
Table 3. Muscle Activity Relative to the Scapula During Throwing
Muscle
Activity
Upper Trapezius
● Clavicle elevation during upward scapula rotation.74
Middle Trapezius
● Acromion elevation during upward scapula rotation.74
● Medial translation of the scapula.74
Lower Trapezius
● Stabilization of the medial scapula during upward scapula rotation.74
● Maintenance of upward scapula rotation past 90o of humeral abduction.76
Serratus Anterior
● Stabilization of the medial border and inferior angle of the scapula during
upward scapula rotation.77
○ Prevents excess winging of scapula.
● External rotation of scapula as humerus abducts.77
Rhomboids
● Medial translation of the scapula.75
Pectoralis Minor
● Anterior tilt and internal rotation of the scapula.78
Gluteus Medius
● Ipsilateral activation synchronously with scapula muscle activation.79
○ Subsequent ipsilateral and contralateral activation to stabilize trunk
during energy transfer to arm.
Proximal Shoulder Musculature
● Provide stable base of support for efficient transfer of energy from legs and
core to arm.80,81
The number of motions, positions, and muscles involved with scapula kinematics serve to illustrate that in the absence of a normal
movement and activation pattern, performance may decrease and risk of injury will increase.58 For instance, previous research has
implicated altered activation of the lower trapezius with an increased risk of developing subacromial impingement.82-4 This altered
activation pattern is likely a result of muscle fatigue leading to a decrease in recruitment of the lower trapezius.85 In addition to
subacromial impingement, scapular dyskinesis has also been observed in up to 94% of athletes suffering from labral injuries.86,87
An association has also been found between scapular dyskinesis and elbow injuries.88-90 The prevailing theory surrounding the
role of scapular dyskinesis in elbow injuries is that alterations in scapulohumeral rhythm cause alterations in elbow mechanics.
The changes in mechanics at the elbow result in an increased valgus load at the medial elbow, which play a role in several common
elbow pathologies including UCL sprains.90 When considering the association between scapular dyskinesis and injuries in the
throwing arm, it makes sense that scapular mechanics are addressed in many measures intended to prevent injuries in pitchers.
PREVENTATIVE PROGRAMS
As outlined earlier in this manuscript, shoulder and elbow injuries cause several detrimental consequences for baseball pitchers.13
When considering the amount of time lost with both operative and nonoperative interventions to address significant shoulder and
elbow injuries, injury risk reduction can play a key role in decreasing the amount of time pitchers are unable to participate in
competition and practice. With the rate of shoulder and elbow injuries continuing to increase in competitive baseball pitchers, more
researchers, clinicians, and coaches have sought to identify the biggest predictors to address with preventative programs.91-93
While a variety of factors can contribute to prevalence of shoulder and elbow injuries, there is general agreement that early sport
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specialization, greater pitch volume, increased pitch velocity, and the use of breaking pitches increases risk of arm injury.94-98
Another predictor that has been identified is GIRD.6,99-102 In fact, decrease in internal rotation as small as 5o compared bilaterally
have been associated with an increased risk of upper extremity injury.103,104,113
In consideration of these predictors, clinicians and coaches often incorporate preventative programs intended to improve shoulder
range of motion without sacrificing dynamic stability of the glenohumeral joint.105-112 Some of these range of motion deficits,
particularly internal rotation and horizontal adduction, have been associated with tight posterior shoulder tissue.106-112 Improving
these two ranges of motion appear to have a protective effect on the shoulder, with previous research demonstrating a decrease
in injury risk with increased shoulder internal rotation and horizontal adduction.105 Many programs incorporate stretching protocols
including the sleeper stretch (Figure 1) to address this posterior capsule tightness.106-112 While the sleeper stretch can be helpful,
it is very important to educate the athlete on the proper mechanics of the stretch and it being done correctly.
Figure 1. Sleeper Stretch
While posterior capsule tightness is an issue that does not contain many variables, the remaining aspects of preventative programs
can be significantly more complex. One of the primary issues with creating an effective throwing program is referred to as the
“Thrower’s Paradox”.48 The Thrower’s Paradox is a term coined by Wilk et al48 to describe the need for the throwing athlete’s
shoulder to be mobile enough to throw yet stable enough to prevent injury. This conundrum has led to varying theories about how
much emphasis to place on both mobility and stability in the thrower’s shoulder. This paradox combined with the fact that there are
an increasing number of commercially available arm care programs has made it difficult for clinicians, coaches, and athletes to
choose the most appropriate preventative program to meet the needs of the individual athlete.113 This lack of a standardized
methodology for preventing shoulder and elbow injuries in baseball pitchers has made it difficult to assess the effectiveness of the
various preventative programs available on the open market. Nevertheless, there have been common aspects of preventative
programs that have been identified.114 These components are detailed in Table 4.
Table 4. Common Components of Preventative Programs for Overhead Athletes
Components
Dynamic warm up
Adequate shoulder and elbow mobility
Maintenance of shoulder rotational strength, scapular stabilization, and
muscular endurance
Reasonable workload management
Recovery that allows for decreased inflammation and maintenance of
flexibility and strength
RETURN TO THROWING
Even with more emphasis being placed on preventing shoulder and elbow injuries in pitchers, the prevalence of these injuries
continues to increase.91-93 Even with injuries necessitating surgical intervention, the majority of pitchers begin therapeutic exercise
within two weeks of surgery.114 Initially, rehabilitation interventions focus on improving strength and range of motion of the involved
and surrounding structures.114 When it is medically appropriate, clinicians need to be able to prepare and implement interval
throwing programs before returning previously injured baseball pitchers to sport. The goals of the various phases of healing and
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rehabilitation are intended to advance patients back to return to activity.6 Clinicians begin by attempting to manage pain and other
symptoms of inflammation, while improving range of motion and mitigating the effects of muscle atrophy.6 As range of motion
improves, exercises are incorporated to improve strength and address in muscle imbalances that have arisen.6 Once patients
demonstrate adequate strength, range of motion, and neuromuscular control, patients begin an interval throwing program intended
return the patient to pitching from the mound.6 Progression and advancement from phase to phase is largely based on the individual
patient and particular pathology. Clinicians should be mindful that a patient may move both forward and backward between phases
as they progress through the rehabilitation process.6 Table 5 presents the recovery timeline for 530 pitchers who underwent UCL
reconstruction.114
Table 5. Time From Surgery to Recovery Milestones Among 530 Professional Pitchers Following UCL Reconstruction111
Milestone
Time From Surgery
Begin rehabilitation
Within 1 week = 51% (269)
Within 2 weeks = 30% (158)
Within 3 weeks = 8% (42)
Don’t know or haven’t started = 2% (11)
Begin interval throwing program
4 months = 31% (161)
5 months = 27% (141)
6 months = 21% (111)
More than 6 months = 7% (35)
Don’t know or still in rehab = 11% (55)
First throw off a mound
4-6 months = 6% (31)
7-9 months = 43% (225)
10-12 months = 29% (150)
Don’t know or still in rehab = 18% (93)
These findings demonstrated that, even at the most elite levels, there is still wide variability related to the initiation of interval
throwing programs following injury.114 There is currently no agreed upon criteria for the initiation of such programs, but there is a
general consensus that such criteria needs to be established.115,116 Notable suggestions for necessary milestones prior to beginning
a return to throwing program include: adequate length of time post-surgical intervention, a concerted transition from the
strengthening phase of therapeutic exercise to a plyometric phase of therapeutic exercise, symmetrical strength in the upper
extremity, an appropriate shoulder external rotation to internal rotation strength ratio, adequate glenohumeral and scapular
stabilizer muscular endurance, and restoration of the glenohumeral rotational arc.115-117 Exact guidelines for adequate strength
before beginning an interval throwing program are difficult to find in the current literature. A meta-analysis of 15 studies describing
return to throwing criteria following UCL reconstruction found that none of the included studies provided a quantitative or qualitative
level of strength that needed be achieve before beginning throwing.116 Nevertheless, further research is needed to be able to
provide quantifiable strength ratios to use as benchmarks. Previous research
Once a pitcher has been cleared to begin a return to throwing program, there is also a lack of consensus on what such a throwing
program should include. Interval throwing programs are recognized as crucial components of returning to sport for pitchers.118
However, the majority of publicly available interval throwing programs lack individualization and incorporate prescriptions of
distance, volume, and intensity that are in many cases arbitrary.118,119 In order to apply the best possible evidence to prescribing
and administering interval throwing programs, there is a need for a common conceptual framework to be established.120 Doing so
will allow for a more standardized methodology that is easier to evaluate for effectiveness.
In the time it will take to establish a general consensus on interval throwing programs, clinicians, coaches, and athletes will continue
to see a gradual change in the current approach to interval throwing programs.118 There is a growing recognition of the need for
individualized interval throwing programs that are more proactive and less reactive.118 As these changes are implemented, it is
important for all stakeholders to be adaptable and open to shifting the approach to interval throwing programs. Even with these
adjustments to the current approach, it should be noted that there are aspects of past and current interval throwing programs that
still warrant inclusion in the future of rehabilitation for injured pitchers.
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Two areas in which past and current interval throwing programs have excelled are recognizing the need for biological healing, and
acknowledging the need to adjust throwing prescriptions based off adverse reactions to throwing load.118 Within these early interval
throwing programs, there has been a particular emphasis placed on physician clearance to ensure adequate tissue healing had
taken place.121,122 These programs also recognized the need to gradually introduce mechanical stress to the previously injured
tissue to allow for adaptation to pitching-specific demands.121
At the time, these programs relied on the manipulation of throwing volume, throwing distance, and throwing effort level to
progressively introduce mechanical stress on the targeted tissue.121 This aspect of previous interval throwing programs is
potentially problematic due to its reliance on perceived effort. Previous research has shown that a perceived 75% effort throw
results in medial elbow torque of 93% of maximum and throw velocity of 86% of maximum.123 Throws at 50% perceived effort
resulted in elbow torque of 87% of maximum and throw velocity of 78% of maximum.123 This demonstrated that decreases in
perceived effort did not result in proportionate decreases in stress on the elbow.
Although many of the presently used interval throwing programs still utilize the same prescription methods for volume and intensity
of throwing, there have been some advances. For instance, a number current interval throwing programs look for functional
milestones to determine readiness to advance a throwing program.124 These milestones may include adequate range of motion
and strength, motor patterns that do not involve compensatory adaptations, and completion of a plyometric program targeting the
shoulder.115 The suggestion has also been made to assess readiness of the lower extremities and core prior to initiating an interval
throwing program.115
Another shift in interval throwing programs has been the use of available external monitoring methods.115 This has served to help
guide modifications to prescribed effort and volume.115 The goal of monitoring metrics when able is to identify potential risks for
reinjury based off decreases in performance.115 This expands on the previous concept of ensuring appropriate tissue healing in
order to continue to advancing interval throwing programs for injured athletes. Current measurement techniques include
subjective feedback from the pitcher, and measures of performance including shoulder and elbow biomechanics and throwing
velocity.115,125 While there is no agreed upon methodology for tracking these metrics, there is general agreement that some
application of them is valuable for monitoring progress of interval throwing programs, modifying progressions, and increasing
dialogue between clinicians, coaches, and pitchers.115,118,125,126 As such, measures that are not validated, but have been
developed specifically for a rehabilitation program or training center may have more practical applications in their given setting.118
The previously mentioned performance based measures have the potential to be primary drivers when determining pitcher
readiness for progressing during their interval throwing program.118 Recent technological advances have allowed for improved
capture and analysis of the biomechanical aspects of pitching.127 Two commercially available methods of measuring the
biomechanical components and stresses placed on the arm during throwing are motion capture systems and interior monitoring
units (IMUs).127 Motion capture systems are a method of collecting video of athletes performing physical activity using a series of
cameras positioned around the athlete, often when reflective markers on the athlete’s body.118 These systems provide clinicians,
researchers, coaches, and athletes the ability to assess throwing kinematics, biomechanical efficiency, and relative stress upon
the body.118 This information proves valuable when considering the individual efficiency of different pitchers’ throwing patterns. For
instance, a pitcher with better throwing efficiency will place less stress on their arm than a pitcher with less throwing efficiency.128
This information can be useful when considering individualized prescriptions of volume, frequency, and intensity of throwing.
Despite their accuracy and value, motion capture systems are often expensive and require additional knowledge and training to
operate appropriately.118
Because of the costs and training associated with motion capture systems, IMUs are often a more feasible option for gathering
performance-based measures. Interior monitoring units are small, wearable devices that have been posited to give clinicians,
coaches, and pitchers objective data about joint and limb angles, arm velocity, and overall mechanical stress experienced by the
shoulder and elbow during throwing.129-131 If worn throughout the entirety of practice and competition, IMUs can also provide a
more accurate count for the number of throws an athlete is performing.118 This alone can prove valuable as previous studies have
noted that the majority of a pitcher makes during practice and competition days go unaccounted for when quantifying workload.131-
133 Information on both acute and chronic workloads can be valuable for predicting risk of injury. Acute workload increases have
been shown to be correlated with an increased risk of injury.134,135 Athletes undergoing higher chronic workloads have also been
associated with increased risk of injury when compared to lower chronic workloads when acute workload increases are
introduced.134,135This improved understanding of the workload a pitcher’s arm undergoes can be beneficial when modifying and
adapting their individual throwing program.
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In the event that a clinician, coach, or pitcher does not have access to either a motion capture system or IMU, a radar gun may still
provide valuable information.117 While more research needs to be done to determine the correlation between throw velocity and
stress at the shoulder and elbow, radar guns can provide information related to the intensity of a throw.117 This intensity can then
serve as a surrogate marker for actual effort.117 Combining radar gun measurements with concurrent subjective feedback from a
pitcher regarding their perceived effort also serves to provide valuable information for the clinician, coach, and pitcher regarding
the stress undergone by the throwing arm.117 Even in light of this ever developing theoretical framework for monitoring stresses
undergone by pitchers’ throwing arms, clinicians, coaches, and pitchers still have to be able to make practical adaptations relative
to their available resources. Even if the only available information is subjective feedback, clinicians, coaches, and pitchers still
need to be able to interpret and apply this information to modifications to interval throwing programs for rehabilitating pitchers.
As interval throwing programs continue to adapt and evolve, newly developed preventative programs and interval throwing
programs must consider the need to determine the actual internal and external stresses the throwing arm undergoes during
pitching.117 As understanding of these stresses grows, interval throwing programs and injury risk reduction programs will continue
to improve and become more proactive. Additionally, a decreased load should not be the goal in every situation. Previous research
has shown that over the course of a baseball season, the UCL grows thicker and more lax under valgus stress at 30o of elbow
extension.13 Conversely, when there was a decrease in throwing, the UCL grew thinner and stiffer under valgus stress at 30o of
elbow extension.136 These anatomic and physiological adaptations must be considered when determining load management at all
phases of a pitcher’s career.
Clinicians and coaches must also consider other individual and contextual factors that may influence sport performance and injury
risk on an individual basis. Individual factors include: genetics, general and current psychological state, years of training, and style
and volume of training.126,137 Contextual factors include: environment considerations such as playing surface and level of
competition, relationships with coaches, trust in the sports medicine team providing healthcare, social background, and cultural
background.126,137 These factors may be difficult to quantify or modify, but still need to be considered due to their potential impact
on a pitcher’s performance capabilities from session to session.
As throwing programs continue to grow and change, there will also be a need to strike a balance between rehabilitation and sport
performance.138 In a traditional rehabilitative mindset, the goal is to prioritize tissue health over sport performance.139 However,
even today there has already been a shift to viewing interval throwing programs as having a dual purpose.117 This places the onus
on the clinician to be able to view the interval throwing program from both rehabilitative and performance based perspectives. In
the future, this will likely lead to the establishment of new throwing parameters, increased integration of objective measurement of
performance, emphasis on recovery post interval throwing program session, and additional feedback and training designed to
optimize performance along with health.117 There will likely never come a time where there will not be some generalization to time
and criteria involved in interval throwing programs. Even so, the individualization of throwing programs will continue to see greater
emphasis.140 From the authors’ perspective, this individualization will incorporate a recognition of the mental health concerns
associated with returning to sport following injury, as well as the positive effects of goal setting.
Goal Setting
A systematic review of the literature strongly suggests that addressing psychological factors during athletes’ return to play (RTP)
are vital components for optimal and full recovery with poor recovery often related to poor adherence to medical treatment and
rehabilitation efforts post recovery.141,142 Goal setting is one such intervention commonly used to address psychological well-being
and has shown to be effective within the sports and exercise realms.143 Goal setting can positively affect multiple facets of
psychological well-being including decreased anxiety and kinesiophobia, improved motivation, persistence, and psychological
coping through cognitive and emotional regulation skill development, improved self-efficacy and self-confidence regarding
rehabilitation and treatment, treatment adherence and effort during rehabilitation.141,144-150 These positive effects are likely due to
the focused attention and direction offered through goal setting.144,151
The performance enhancement seen with goal setting in athletes is widely believed to be influenced by two well researched and
documented relationships with goal setting; the self-determination theory and theory of planned behavior.142,152,153 Goal setting post
injury, according to the self-determination theory, is a collaborative approach of setting markers for achievement in recovery
processes that leads to greater feelings of autonomy and increase intrinsic motivation. Said another way, this intervention helps
athletes feel more in control of their experience and resulting in improved internal motivation and engagement in appropriate
recovery behaviors.142,154 Collaborative goal development amongst the health care team and athletes leads to increased feelings
of support, inclusion in treatment plan development, and increase athlete’s sense of self competency regarding the recovery
process. All are vital components to engaging in appropriate health behaviors for recovery.142
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Experts in goal setting specifically with athletes cite three specific types of goals; outcome, process, and performance goals with
each type serving a specific purpose: outcome (win championship), process (making a plan for the steps needed to accomplish a
specific goal), performance (increasing goal percentage by 10%) citing improved goal achievement rates when used collaboratively
versus separate that are time limited and specific.143,144,149 Specifically for athletes, process-oriented goals, or those focused on
building effective, helpful, and supportive habits toward continued growth and improvement are most beneficial in recovery
efforts.143 Ultimately, when developing goals during recovery, it is very important to make all goals moderately difficult versus easy
or even hard, as the former can decrease motivation and follow-through. While similarly, too challenging of goals can have a
negative impact on individuals’ motivation, frustration levels, and self-confidence leading to decreased performance.142 Research
looking at “moderate” versus “difficult” goals suggest that no more than 5% above current performance levels should be set for
optimal achievement and should be collaboratively set with the athlete whereas they can weigh in on their self-efficacy with regards
to goal achievement.143 Finally, without this guidance, individuals cannot self-moderate their actions and make adjustments
necessary to achieve their goals.144 This is also true of athletes recovering from injury.148 Overall, research supports the use of
goal setting as a valuable tool during rehabilitation from injury.149
Return to the Pitching Mound
Having considered the past, present, and future of interval throwing programs along with the role individualized goal setting can
have on optimal patient outcomes, it is important to consider the ultimate goal of the majority of injured pitchers. Namely, pitchers
who have sustained an injury and intend to continue their career will need to progress toward throwing from a pitching mound.
Once this milestone has been met, mechanical stress will have to be gradually increased, similar to the flat ground portion of an
interval throwing program. As with other aspects of returning pitchers to sport participation, returning to pitching from the mound
has also become increasingly scrutinized in both research and performance settings.
Returning to pitching from the mound involves similar benchmarks to start a returning to throwing program beginning with throwing
from flat ground and progressing to throwing from a pitching mound. Specifically, pitchers need to demonstrate appropriate
shoulder range of motion, muscular strength, adequate glenohumeral and scapular stabilizer muscular endurance, lower extremity
and trunk control, and an appropriate amount of time for the pathologic tissue to heal.114,120,121 Another traditionally important
benchmark for returning to the mound is distance of throws completed on flatground.121 One study reported the average longest
throw prior to returning to pitching from the mound was 137.5 feet (range = 105-300 feet).121 The rationale behind having to meet
a distance requirement has largely been to ensure that the pitcher has adequate muscular strength and endurance to withstand
the stress placed on the arm when pitching from a mound.114,120,121 Recent studies, however, have called this thought process into
question.
These studies have shown that throwing from a distance of 120 feet or further places stress on the elbow and shoulder equal to or
greater than the stresses typically experienced when pitching in a competition.157-160 Additionally, the mound has been shown to
provide pitchers with a mechanical advantage.156 Pitchers throwing on flat ground, even at distances shorter than 60.5 feet had
similar biomechanical stresses to those pitching from a mound, and were throwing with significantly lower ball velocity.156 This has
led to the relatively recent suggestion that pitching from a mound can actually provide a protective effect for the shoulder and
elbow.156 Despite this new information, there is still a place for throwing at longer distances. Throwing at these longer distances
still has the potential to provide a benefit from a shoulder range of motion, and arm speed standpoint.161 However, this throwing
should be done with caution, as throwing mechanics with long-toss are different than those with pitching from the mound.162 These
differences grow even more variable as distance increases and the path of throws grows less linear.162
When pitchers do reach the necessary benchmarks and receive physician clearance, there are more considerations to returning
to pitching from the mound than simply gradually increasing the stress experienced by the shoulder and elbow. As pitchers return
to pitching from the mound, there is an opportunity to incorporate a sports performance mindset without neglecting the rehabilitative
aspects of the process. As pitchers return to the mound, clinicians and coaches should be cognizant of anatomical mechanical
variables that increase pitch efficiency and velocity.129,130 It has been previously noted that more efficient mechanics generate less
stress at the shoulder and elbow, and therefore reduce the risk of injury.127 This creates a prime opportunity for blending sports
performance with rehabilitation and injury risk reduction. Some of these anatomical variables may not be able to be adjusted, such
as humeral length, radial length, and humeral torsion.129 Still, there are anatomic mechanical variables that when adjusted can
improve mechanical efficiency and pitch velocity. These variables are listed in Table 6.
A final aspect of returning to pitching that warrants consideration is the role of training with weighted balls. The use of weighted
balls has been widely reported among baseball pitchers, even those who believe using weighted balls for training may increase
injury risk.163 These balls generally range in weight from 2 oz to over 32 oz, and are used with the intent of improving pitch
velocity and accuracy.164,165 The popularity of weighted ball programs appears to come from the belief that use of weighted balls
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in training will improve performance.48,163-168 Although popularity of these weighted ball programs has grown, there are still
aspects that need to be addressed through research.
Table 6. Variables Affecting Pitch Efficiency and Velocity129
Variable
Increased body mass
Shorter interval from stride foot contact and terminal glenohumeral external
rotation
Increased knee flexion at stride foot contact
Increased elbow flexion at stride foot contact
Later forward head movement relative to the hips
Increased maximum glenohumeral external rotation
Increased angular velocity of elbow flexion
Increased angular velocity of thoracic spine rotation
Increased knee flexion at ball release
Increased forward trunk tilt at ball release
First, there is no standardized methodology for the use of weighted balls in pitcher training.163 This lack of standardized methods
makes it difficult for clinicians and researchers to establish guidelines founded in scientific evidence.163 In the absence of better
scientific evidence, clinicians, coaches, and pitchers often have to rely on anecdotal recommendations and commercial programs
for current best practices related to implementing weighted balls into training. Additionally, recent research has suggested that
weighted ball programs may increase the risk of throwing arm injuries in pitchers.105,163 Even with this evidence, pitchers still report
a general intent to continue to use weighted balls in their training due to the perceived improvement in performance related to
training with weighted balls.163 This places a responsibility on clinicians and coaches to play a more active role in safely
implementing weighted balls into throwing programs.163 Prior to initiating the use of weighted balls during the throwing program,
certain safety measures should be taken including: musculoskeletal maturity, proper mechanics, and appropriate supervision.105
As this literature review illustrates, there are a number of factors that come into play when attempting to return a baseball pitcher
to pitching from the mound. Clinicians, coaches, and pitchers must be proactive, adaptive, intentional, and thorough when
monitoring and progressing a previously injured pitcher as they return to pitching from the mound. To further expand on this, the
remainder of this manuscript presents the cases of two previously injured collegiate baseball pitchers and their return to pitching
from the mound. While this manuscript is not intended to serve as an exhaustive literature review or definitive statement on throwing
programs, it is intended to add to the current literature on return to pitching programs and present new or more fully realized ideas
on adaptations and advances in the field.
CASE PRESENTATION
Patient 1
The first patient was a 23-year-old, right-hand dominant, NCAA Division II baseball pitcher. The patient had no previous history of
shoulder pathology but had undergone UCL reconstruction four years earlier. The previous season, the patient had pitched 54
innings at a two-year institution of higher education. Prior to that season, the patient had not pitched an inning in a competitive
setting for three years. As the previous season progressed, the patient began to feel increasing levels of discomfort in the anterior
shoulder and the anterior border of the axilla during the late cocking and acceleration phases of pitching. The patient did not have
regular access to athletic trainers or other healthcare professionals at his previous institution and had to rely on home programs to
attempt to address his discomfort. At the conclusion of the previous season, the patient took one week off for rest and began to
increase volume and intensity of throwing over the next five weeks. After taking another week off, the patient began to increase
volume and intensity again for the next seven weeks.
While the patient’s symptoms had improved with rest, beginning to throw again caused symptoms to return. Initial evaluation by
the athletic training staff yielded findings consistent with subacromial impingement and posterior capsule tightness in the patient’s
throwing shoulder. After seven weeks of rehabilitation and treatment designed to improve strength and range of motion, the
patient’s symptoms showed no significant improvements. At this time, the athletic training staff referred the patient to their team
physician. Upon receiving an x-ray and MRI arthrogram (Figure 2), the patient’s diagnosis was updated to a mild fraying of the
posterior labrum extending from the 8:00 to 10:00 position and fraying along the critical zone of the infraspinatus tendon. The
patient expressed frustration at potentially having his position as a starting pitcher jeopardized by his current injury. The athletic
trainer and team physician assured the patient that there was still time to pursue treatment options that would allow him to return
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to his previous role on his team. Additionally, the patient was assured that he would have the ability to assist with developing his
return to competition protocol and provide feedback on steps being taken to progress him back to sport. At this time the patient
consented to receiving a platelet rich plasma injection in the pathologic sites, after which an interval throwing program would be
initiated.
Figure 2. Shoulder MRI
Interventions
One week after reporting to the athletic training staff, the patient was seen to receive treatment in the form of PRP injections in his
shoulder. 15 mL of whole blood was collected via phlebotomy, and successfully spun in a centrifuge (Arthrex ACP PRP System,
Arthrex, Inc., Naples, FL). Through this process 4 mL of PRP was concentrated. After the treatment site was cleansed with
chlorhexidine, 2 mL of PRP was injected into the posterior glenohumeral joint under ultrasound guidance with a 25-gauge needle.
The remaining 2 mL of PRP was injected in the long axis under ultrasound guidance into the deep aspect of the infraspinatus at
the insertion, and fanned both anteriorly and posteriorly, with a trace amount of PRP being injected into the subacromial bursa.
The procedure was well tolerated and did not result in any complications. Following the procedure, the patient was given
instructions to follow up with his athletic trainer to establish the remainder of his plan of care. The plan of care was based off expert
opinion in consultation with three physicians who had extensive experience using PRP injections to treat shoulder pathologies.
The first week after receiving his PRP injections, the patient was instructed to restrict physical activity involving the shoulder to
activities of daily living. The second week, the patient began to perform static stretches three times per day to improve range of
motion of his shoulder. The third week, the patient began to progress into isometric exercises for shoulder: abduction, adduction,
internal rotation, external rotation, and flexion. During the third week, the athletic trainer, head baseball coach, pitching coach, and
patient met to discuss the patient’s goals for their interval throwing program. The patient stated a desire to be able to pitch
approximately four innings during the opening weekend of the season. With pitching four innings on opening weekend as an end
goal for the patient’s interval throwing program, the athletic trainer created a calendar to help guide the discussion.
Once the date of the patient’s goal was established, the athletic trainer and pitching coach met with the patient to discuss what
milestones he would need to meet in order to achieve his goal. The patient, athletic trainer, pitching coach, and team physician
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agreed that the patient would need to be able to throw a 20-pitch bullpen at 100% effort four weeks prior to the opening week of
the season. This would place the patient in a position to participate in practice in a manner that would allow him to throw four
innings during the opening weekend of the season. In order to reach the point where he could throw a 100% effort bullpen, the
patient would need to throw seven bullpens of gradually increasing intensity and volume. These bullpens were incorporated into
the calendar along with the patient’s flat ground throwing and rest on non-bullpen days. After these milestones were discussed,
the athletic trainer and pitching coach began laying out the throwing program using a calendar template in Microsoft Word
(Microsoft, Redmond, WA). Rather than calculating progression of volume from the beginning of the program in an ascending
manner, regressions of volume were calculated from the end of the program in a descending manner as described in Table 7.
Upon finishing the calendar, the athletic trainer and pitching coach confirmed that the timeline was realistic for the patient’s goals.
To calculate the target velocity for when the patient was throwing from flat ground, the patient’s previous maximum velocity of 90
miles per hour on flat ground was used. To calculate the target velocity for when the patient was pitching from the mound, a
maximum velocity of 95 miles per hour was used. Sets, repetitions, and intensity of throws are presented in Table 7. Prior to each
throwing session, the patient completed a dynamic warmup consisting of high knees, walking lunges, A skips, B skips, and
resistance tubing exercises for shoulder internal rotation, external rotation, abduction, flexion, and extension. Following each
throwing session, the patient completed the rehabilitation protocol described in Table 8. During each throwing session, the athletic
trainer, pitching coach, or a teammate was present to use a radar gun to ensure that the patient was maintaining his target velocity.
During the patient’s bullpen on Day 71, the patient reached 91 mph velocity. This velocity was within 4.2% of his maximum velocity
prior to injury. At this time, the patient was cleared to return to full practice and competition participation without issue.
Table 7. Patient 1 Interval Throwing Program Progression
0.10
Throws
Percentage of Max Velocity
Target Velocity
Day 1 & 2
2x20
70%
63-69 mph
Day 3 & 4
Rest
Rest
Rest
Day 5 & 6
2x30
70%
63-69 mph
Day 7
1x20
70%
63-69 mph
Day 8 & 9
2x20
75%
68-75 mph
Day 10 & 11
Rest
Rest
Rest mph
Day 12 & 13
2x30
75%
68-75 mph
Day 14
1x20
75%
68-75 mph
Day 15 & 16
2x20
80%
72-79 mph
Day 17 & 18
Rest
Rest
Rest
Day 19 & 20
2x30
80%
72-79 mph
Day 21
1x20
80%
72-79 mph
Day 22 & 23
2x20
85%
77-83 mph
Day 24 & 25
Rest
Rest
Rest
Day 26 & 27
2x30
85%
77-83 mph
Day 28
1x20
85%
77-83 mph
Day 29 & 30
2x20
90%
81-87 mph
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©The Internet Journal of Allied Health Sciences and Practice, 2025
0.10
Throws
Percentage of Max Velocity
Target Velocity
Day 31 & 32
Rest
Rest
Rest
Day 33 & 34
3x20
90%
81-87 mph
Day 35
1x20
90%
81-87 mph
Day 36*
1x20 Bullpen
70%
63-69 mph
Day 37
Recovery
Recovery
Recovery
Day 38-42
≤ 40 at max
95%
85-90 mph
Day 43
1x30 Bullpen
80%
76-79 mph
Day 44
Recovery
Recovery
Recovery
Day 45 & 46
Rest
Rest
Rest
Day 47
1x20 Bullpen
70%
63-69 mph
Day 48 & 49
≤ 40 at max
95%
85-90 mph
Day 50
1x30 Bullpen
80%
76-79 mph
Day 51
Recovery
Recovery
Recovery
Day 52
Rest
Rest
Rest
Day 53
≤ 40 at Max
95%
85-90 mph
Day 54
1x20 Bullpen
75%
71-75
Day 55 & 56
≤ 40 at Max
95%
85-90 mph
Day 57
1x20 Bullpen
85%
81-85
Day 58
Recovery
Recovery
Recovery
Day 59
Rest
Rest
Rest
Day 60-63
≤ 40 at Max
95%
85-90 mph
Day 64
1x20 Bullpen
90%
86-90 mph
Day 65
Recovery
Recovery
Recovery
Day 66
Rest
Rest
Rest
Day 67-70
≤ 40 at Max
95%
85-90 mph
Day 71
1x20 Bullpen
100%
95+ mph
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Table 8. Rehabilitation Exercises Completed by Patient 1 After Each Throwing Session
Exercise
Sets x Repetitions with 50%
Blood Flow Restriction
Shoulder external rotation at 90o shoulder
abduction and 90o elbow flexion
1x30
3x15
Shoulder internal rotation at 0o shoulder
abduction and 90o elbow flexion
1x30
3x15
Shoulder external rotation at 0o shoulder
abduction and 90o elbow flexion
1x30
3x15
Shoulder flexion at 45o horizontal abduction
and 0o elbow flexion
1x30
3x15
Patient 2
The second patient was a 23-year-old, left-hand dominant, NCAA Division II baseball pitcher. The patient reported to the athletic
training staff after experiencing pain, stiffness, and ecchymosis in the medial aspect of his left elbow following pitching earlier in
the day. The patient did not report any single pitch that resulted in onset of symptoms but did note that he experienced increasing
tightness throughout his time pitching that day. Given the patient’s intensity of symptoms, the patient was referred to the team
physician the following day. Upon receiving an x-ray and MRI arthrogram (Figure 3), the patient’s diagnosis was confirmed as a
partial UCL tear at the proximal attachment site. Throughout the diagnostic process, the patient expressed disappointment at being
injured. The patient related that the timeline of this injury coincided with a previous injury he had sustained the previous year that
had restricted his offseason baseball activities. The athletic trainer and team physician attempted to reassure the patient by
reminding him that his plan of care would have him ready for participating in his team’s championship season. The sports medicine
staff also made a point of involving the patient in the decision-making process when determining his return to competition protocol.
Given the location and extent of the tear, the patient was educated and consented to receive a platelet rich plasma injection in the
pathologic site, after which an interval throwing program would be initiated.
Figure 3. Elbow MRI
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Interventions
Two weeks after the injury, the patient was seen in the team physician’s office for PRP injections. A total of 15 mL of whole blood
was collected using phlebotomy. The patient’s blood was then successfully spun in the previously mentioned centrifuge system,
resulting in the concentration of 6 mL of PRP. After the treatment site was cleansed with chlorhexidine, 4 mL of PRP was injected
into the left UCL under ultrasound guidance with a 25-gauge needle. The remaining 2 mL of PRP was injected superficially into
the common flexor soft tissue, and the area of previously noted soft tissue swelling. The procedure was well tolerated and did not
result in any complications. Following the procedure, the patient was instructed to follow up with his athletic trainer to establish the
remainder of his plan of care.
The first week after receiving his PRP injections, the patient was instructed to restrict physical activity involving his left arm to
activities of daily living. The patient reported stiffness the first 24 hours after injection that gradually resolved over the second 24
hours. During this time, the patient continued to perform lower body weightlifting exercises to maintain physical fitness. The second
week, the patient began to perform static stretches three times per day to improve range of motion of his shoulder, wrist, and
elbow. The third week, the patient began to progress into isometric exercises for shoulder: abduction, adduction, internal rotation,
external rotation, and flexion, and resistance exercises to improve grip strength, wrist extension and flexion, and pronation and
supination. During the third work, the athletic trainer, head baseball coach, pitching coach, and patient met to discuss the patient’s
goals for their interval throwing program. The patient stated a desire to be able to pitch to live hitters the week before the opening
weekend of the season. The patient felt that reaching this goal would place him in a position to be ready to pitch in competition by
the third week of the season. With pitching to live hitters the week before opening weekend as an end goal for the patient’s interval
throwing program, the athletic trainer created a calendar to help guide the discussion.
Once the date of the patient’s goal was established, the athletic trainer and pitching coach met with the patient to discuss what
milestones he would need to reach in order to achieve his goal. The patient, athletic trainer, pitching coach, and team physician
agreed that the patient would need to be able to throw a 20-pitch bullpen at 100% effort two weeks prior to the competition the
patient hoped to pitch in. This would provide the patient with adequate time to prepare for pitching against live hitters. Similar to
the first patient described, the patient would need to throw seven bullpens of gradually increasing intensity and volume. After these
milestones were discussed, the athletic trainer and pitching coach began laying out the throwing program using a calendar template
in Microsoft Word (Microsoft, Redmond, WA). Rather than calculating progression of volume from the beginning of the program in
an ascending manner, regressions of volume were calculated from the end of the program in a descending manner. Upon finishing
the calendar, the athletic trainer and pitching coach confirmed that the timeline was realistic for the patient’s goals.
To calculate the target velocity for when the patient was throwing from flat ground, the patient’s previous maximum velocity of 85
miles per hour on flat ground was used. To calculate the target velocity for when the patient was pitching from the mound, a
maximum velocity of 86 miles per hour was used. Sets, repetitions, and intensity of throws were progressed in the same manner
as previously described for the first patient. As with the first patient, after each throwing session the patient completed a dynamic
warmup consisting of high knees, walking lunges, A skips, B skips, and resistance tubing exercises for shoulder internal rotation,
external rotation, abduction, flexion, and extension. Following each throwing session, the patient completed the rehabilitation
protocol described in Table 9. During each throwing session, the athletic trainer, pitching coach, or a teammate was present to use
a radar gun to ensure that the patient was maintaining his target velocity. During the patient’s first session pitching to live hitters,
the patient reached 87 mph velocity. This pitching velocity was slightly above the highest velocity the patient achieved in
competition the previous season. At this time, the patient was cleared to return to full practice and competition participation without
issue.
Table 9. Rehabilitation Exercises Completed by Patient 2 after each Throwing Session
Exercise
Sets x Repetitions
with 50% Blood Flow
Restriction
Theraputty gripping
3x30 seconds
Wrist flexion with dumbbell
1x30
3x15
Wrist extension with dumbbell
1x30
3x15
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Exercise
Sets x Repetitions
with 50% Blood Flow
Restriction
Pronation/Supination with dumbbell
1x30
3x15
Ulnar deviation with dumbbell
1x30
3x15
DISCUSSION
The purpose of this manuscript was to discuss the currently available literature on throwing programs for baseball pitchers, and to
introduce the concept of a potentially novel approach to interval throwing programs. Increasing upper extremity injury rates for
baseball pitchers have been well documented in present day literature and create the need for identifying predictors for shoulder
and elbow injuries in this population. Previous literature has noted several pitfalls with the current way interval throwing programs.
Many times, current interval throwing programs utilize distance, volume, and perceived intent without respect to individual skill
level, performance capacity, or goals.118,119 Previous authors have gone so far as to call the currently available interval throwing
programs arbitrary.118,119 As further research is conducted to identify these predictors, clinicians, coaches, and pitchers should
work to remain abreast of updates in modern literature. In the interim, it is critical that clinicians and coaches be prepared to develop
individualized, proactive, and adaptable return to pitching programs for injured pitchers.
Timely and accurate diagnosis of pathology affecting a pitcher’s arm is crucial to ensuring appropriate care. This information is
necessary to be able to create a realistic and feasible timeline for returning to pitching from the mound. As this timeline is being
established, it is important to involve the injured pitcher in conversations that are taking place. Specifically, the injured pitcher
should be involved in any conversations related to milestones and goals for their throwing program. Once these milestones and
goals are established, working backward in a descending manner for progression through programming may allow for better
progression to pitching from the mound than working forward in an ascending manner. Allowing the pitcher to be involved in the
goal setting and realistic progression of their interval throwing program may promote compliance by giving them a sense of
ownership in the process of determining their progression. Doing so also creates a better environment for pitchers to develop good
habits related to their attention to detail during arm care programs.
While this review and case report does not provide an exhaustive account of currently available literature, it does provide a
framework for returning baseball pitchers to pitching from the mound. In order to provide objective data, new baseline maximum
velocities should be established at the beginning of each training period for pitchers from both flat ground and the mound. Should
a pitcher demonstrate increased velocity when pitching from the mound, a new flat ground maximum velocity measure should be
taken. Gathering this data at regular intervals will allow for more objective progressions in the event that a pitcher needs to complete
an interval throwing program to return to pitching from the mound.
Care should be taken to ensure that necessary milestones are met in order to initiate an interval throwing program. Namely,
previously injured pitchers should have had adequate time to allow for tissue healing, receive physician clearance, demonstrate
full and symmetrical shoulder range of motion compared bilaterally, and demonstrate adequate and symmetrical shoulder strength
compared bilaterally. As a pitcher nears these milestones, a multidisciplinary team including the athletic trainer and coaching staff
should meet with the pitcher to discuss goals for the upcoming interval throwing program. Once a terminal goal is established, the
group should then work from that goal backwards in a descending fashion to determine the progression in volume and intensity
the pitcher will need to follow. Throughout this process, pitchers and other stakeholders should be reminded that progressions will
be fluid and adaptable pending patient reported symptoms and physician recommendations. For reference, the authors have
constructed a decision matrix outlined by Figure 4.115-117
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Figure 4. Decision Matrix
A possible limitation of this research is the small sample size. Given the nature of case reports, it is difficult to provide generalizable
information through detailing the recovery of two patients. However, this research does apply to cases of patients who successfully
returned to their previous level of competition using this design for an interval throwing program. Another possible limitation of this
research is that long term patient report outcomes were not assessed. Future research should seek to use the principles related
in this literature review and case report to design interval throwing programs for injured baseball pitchers and track long term
outcomes. As more literature becomes available on using objective, individual goal-based throwing programs, larger scale studies
can be designed that allow clinicians, researchers, and coaches to move closer to a consensus on the best methods of creating
and implementing interval throwing programs.
CONCLUSIONS
In the two cases that are presented, it should be noted that neither pitcher required surgical intervention for their pathology.
However, both did receive PRP injections due to the nature of their injuries and the desire to assist in the healing process. Through
a combination of patient compliance, a multidisciplinary approach, and the use of adaptive measures, both patients were able to
return to pitching at velocity at or above their previous maximums. At the institution these two pitchers compete at, the intent is to
continue to use this method of designing interval throwing programs for the foreseeable future until further research can be
conducted to revise and amend the current process.
As clinicians, coaches, and pitchers gain a better understanding of the demands placed on the elbow and shoulder during pitching,
interval throwing programs will continue to evolve from a practical and conceptual standpoint. Future research should be conducted
to objectively measure the value and impact of goal setting on the rehabilitation process and interval throwing programs for baseball
pitchers. Additionally, future research should work to better understand the correlation, or lack thereof, between throw velocity and
mechanical stress at the elbow and shoulder in pitchers.
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©The Internet Journal of Allied Health Sciences and Practice, 2025
Current professional and scholarly opinions differ regarding the progression and content of interval throwing programs. In the
absence of more conclusive evidence, the inclusion of self-developed and self-actualizing goals along with objective measures
have the potential to enhance these programs. Clinicians, coaches, and pitchers should use the resources available to them to
ensure that criteria for progression through an interval throwing program are reasonable and feasible. Additionally, progression of
volume and intensity of these throwing programs should be done on an individual basis giving consideration to type of injury,
severity of injury, and the pitcher’s previous level of performance. If created, evaluated, and progressed from an objective
standpoint, interval throwing programs have the potential to be more proactive, adaptable, and ultimately valuable for pitchers
returning from injury.
REFERENCES:
1. Fleisig GS, Andrews JR, Dillman CJ, Escamilla RF. Kinetics of baseball pitching with implications about injury
mechanisms. Am J Sports Med. 1995;23:233-239.
2. Werner SL, Gill TJ, Murray TA, Cook TD, Hawkins RJ. Relationships between throwing mechanics and shoulder
distraction in professional baseball pitchers. Am J Sports Med. 2001;29:354-358.
3. Fleisig GS, Barrentine SW, Escamilla RF, Andrews JR. Biomechanics of overhand throwing with implications for
injuries. Sports Med. 1996;21:421-437.
4. Escamilla RF, Barrentine SW, Fleisig GS, et al. Pitching biomechanics as a pitcher approaches muscular fatigue
during simulated baseball game. Am J Sports Med. 2007;35:23-33.
5. DiGiovine NM, Jobe FW, Pink M, Perry J. An electromyographic analysis of the upper extremity in pitching. J Shoulder
Elbow Surg. 1992;1:15-25.
6. Reuther KE, Larsen R, Kuhn PD, Kelly JD, Thomas SJ. Sleeper stretch accelerates recovery of glenohumeral internal
rotation after stretching. J Shoulder Elbow Surg. 2016;25:1925-1929.
7. Wilk KE, Arrigo CA, Hooks TR, Andrews JR. Rehabilitation of the overhead throwing athlete: There is more to it than
just external rotation/internal rotation strengthening. Physical Medicine & Rehabilitation. 2016;8:S78-S90.
8. Wasserman EB, Sauers EL, Register-Mihalik JK, et al. The First Decade of Web-Based Sports Injury Surveillance:
Descriptive Epidemiology of Injuries in US High School Boys' Baseball (2005-2006 Through 2013-2014) and National
Collegiate Athletic Association Men's Baseball (2004-2005 Through 2013-2014). J Athl Train. 2019;54(2):198-211.
9. Conte S, Requa RK, Garrick JG. Disability days in major league baseball. Am J Sports Med. 2001;29:431-436.
10. Posner M, Cameron K, Wolf JM, Belmont PL, Owens BD. Epidemiology of Major League Baseball injuries. Am J
Sports Med. 2011;39:1678-1680.
11. Collins CL, Comstock RD. Epidemiological features of high school baseball injuries in the United States, 2005-2007.
Pediatrics. 2008;121:1181-1187.
12. Plummer HA, Plosser SM, Diaz PR, Lobb NJ, Michener LA. Effectiveness of a shoulder exercise program in Division I
collegiate baseball players during the fall season. International Journal of Sports Physical Therapy. 2022;17(2):247-
258.
13. Ievleva L, Orlick T. Mental links to enhance healing: An exploratory study. Sport Psychology. 1991;5(1):25-40.
14. Camp CL, Sinatro A, Spiker A, Werner BC, Altchek DW, Coleman SH, Dines JS. Decreased shoulder external rotation
and flexion are greater predictors of injury than internal rotation deficits: analysis of 132 pitcher-seasons in professional
baseball. Orthop J Sport Med. 2017;5:2325967117S0022.
15. Coughlin RP, Lee Y, Horner NS, Simunovic N, Cadet ER, Ayeni OR. Increased pitch velocity and workload are
common risk factors for ulnar collateral ligament injury in baseball players: a systematic review. J. ISAKOS. 2019.
16. Erickson BJ, Chalmers PN, Axe MJ, Romeo AA. Exceeding pitch count recommendations in little league baseball
increases the chance of requiring Tommy John surgery as a professional baseball pitcher. Orthop J Sport Med.
2017;5.
17. Fleisig GS, Andrews JR. Prevention of elbow injuries in youth baseball pitchers. Sports Health. 2012;4:419–24.
18. Keller RA, De Giacomo AF, Neumann JA, Limpisvasti O, Tibone JE. Glenohumeral internal rotation deficit and risk of
upper extremity injury in overhead athletes: a meta-analysis and systematic review. Sports Health. 2018;10:125–32.
19. Olsen SJ, Fleisig GS, Dun S, Loftice J, Andrews JR. Risk factors for shoulder and elbow injuries in adolescent baseball
pitchers. Am J Sports Med. 2006;34:905–12.
20. Reiman MP, Walker MD, Peters S, Kilborn E, Thigpen CA, Garrigues GE. Risk factors for ulnar collateral ligament
injury in professional and amateur baseball players: a systematic review with meta-analysis. J Shoulder Elb Surg.
2019.
21. Whiteside D, Martini DN, Lepley AS, Zernicke RF, Goulet GC. Predictors of ulnar collateral ligament reconstruction in
major league baseball pitchers. Am J Sports Med. 2016;44:2202–9.
RE-ENVISIONING THROWING PROGRAMS FOR BASEBALL PITCHERS 20
©The Internet Journal of Allied Health Sciences and Practice, 2025
22. Wilk KE, MacRina LC, Fleisig GS, Aune KT, Porterfield RA, Harker P, et al. Deficits in glenohumeral passive range of
motion increase risk of elbow injury in professional baseball pitchers: a prospective study. Am J Sports Med.
2014;42:2075–81.
23. McElheny K, Sgroi T, Carr JB. Efficacy of arm care programs for injury prevention. Current Reviews in Musculoskeletal
Medicine. 2021;14:160-167.
24. Dick R, Sauers EL, Agel J, et al. Descriptive epidemiology of collegiate men’s baseball injuries: National Collegiate
Athletic Association Injury Surveillance System, 1998-1999 through 2003-2004. J Athl Train. 2007;42:183-193.
25. Juel NG, Natvig B. Shoulder diagnoses in secondary care, a one year cohort. BMC Musculoskelet Disord. 2014;15:89.
26. Andrews JR, Carson WG, McLeod WD. Glenoid labrum tears related to the long head of the biceps. Am J Sports Med.
1985;13:337-341.
27. Snyder SJ, Karzel RP, Del Pizzo W, et al. SLAP lesions of the shoulder. Arthroscopy. 1990;6:274-279.
28. Wilk KE, Reinold MM, Dugas JR, et al. Current concepts in the recognition and treatment of superior labral (SLAP)
lesions. J Orthop Sports Phys Ther. 2005;35(5):273-291.
29. Reinold MM, Wilk KE, Hooks TR, et al. Thermal-assisted capsular shrinkage of the glenohumeral joint in overhead
athletes: A 15- to 47- month follow-up. J Orthop Sports Phys Ther. 2003;33:455-467.
30. Carr JB, Camp CL, Dines JS. Elbow ulnar collateral ligament injuries: Indications, management, and outcomes.
Arthroscopy. 2020;36(5):1221-1222.
31. Calabrese CJ. Pitching mechanics, revisited. The International Journal of Sports Physical Therapy. 2013;8(5):652-659.
32. Christopherson ZR, Kennedy J, Roskin D, Moorman CT. Rehabilitation and return to play following superior labral
anterior to posterior repair. Operative Techniques in Sports Medicine. 2017;25:132-144.
33. Burkhart SS, Morgan CD. The peel-back mechanism: Its role in producing and extending posterior type II SLAP lesions
and its effect on SLAP repair rehabilitation. Arthroscopy. 1998;14(6):637-640.
34. Shepherd MF, Dugas JR, Zeng N, et al. Differences in the ultimate strength of the biceps anchor and the generation of
type II superior labral anterior posterior lesions in a cadaveric model. Am J Sports Med. 2004;32:1197-1201.
35. Smith R, Lombardo DJ, Petersen-Fitts GR, et al. Return to play and prior performance in Major League Baseball
pitchers after repair of superior labral anterior-posterior tears. Orthopaedic Journal of Sports Medicine. 2016;4(12).
36. Brockmeier SF, Voos JE, Williams RJ, Altchek DW, Cordasco FA, Allen AA. Outcomes after arthroscopic repair of
type-II SLAP lesions. J Bone Joint Surg Am. 2009;91:1595-1603.
37. Neuman BJ, Boisvert CB, Reiter B, Lawson K, Ciccotti MG, COhen SB. Results of arthroscopic repair of type II
superior labral anterior posterior lesions in overhead athletes: Assessment of return to preinjury playing level and
satisfaction. Am J Sports Med. 2011;39:1883-1888.
38. Jobe FW, Stark H, Lombardo SJ. Reconstruction of the ulnar collateral ligament in athletes. J Bone Joint Surg Am.
1986;68:1158-63.
39. Conway JE, Jobe FW, Glousman RE, et al. Medial instability of the elbow in throwing athletes. Treatment by repair or
reconstruction of the ulnar collateral ligament. J Bone Joint Surg Am. 1992;74:67-83.
40. Azar FM, Andrews JR, Wilk KE, et al. Operative treatment of ulnar collateral ligament injuries of the elbow in athletes.
Am J Sports Med. 2000;28:16-23.
41. Cain EL Jr, Andrews JR, Dugas JR, et al. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281
athletes: Results in 743 athletes with minimum 2-year follow-up. Am J Sports Med. 2010;38:2426-34.
42. Thompson WH, Jobe FW, Yocum LA, et al. Ulnar collateral ligament reconstruction in athletes: muscle-splitting
approach without transposition of the ulnar nerve. J Shoulder Elbow Surg. 2001;10:152-7.
43. Bruce JR, El Attrache NS, Andrews JR. Revision ulnar collateral ligament reconstruction. Journal of the American
Academy of Orthopaedics. 2018;26(11):377-385.
44. Camp CL, Desai V, Conte S, et al. Revision ulnar collateral ligament reconstruction in professional baseball: Current
trends, surgical techniques, and outcomes. Orthopaedic Journal of Sports Medicine. 2019;7(8).
45. Smith MV, Bernholt DL. Ulnar collateral ligament injury in the elbow: Current trends for treatment. Annals of Joint.
2020;5:15.
46. Udall JH, Fitzpatrick MJ, McGarry MH, et al. Effects of flexor-pronator muscle loading on valgus stability of the elbow
with an intact, stretched, and resected medial ulnar collateral ligament. J Shoulder Elbow Surg. 2009;18:773-8.
47. Smucny M, Westermann RW, Winters M, et al. Non-operative management of ulnar collateral ligament injuries in the
throwing athlete. Phys Sportsmed 2017;45:234-8.
48. Wilk KE, Meister K, Andrews JR. Current concepts in the rehabilitation of the overhead throwing athlete. Am J Sports
Med. 2002;30:136-51.
49. Dines JS, Williams PN, ElAttrache N, et al. Platelet-Rich Plasma Can Be Used to Successfully Treat Elbow Ulnar
Collateral Ligament Insufficiency in High-Level Throwers. Am J Orthop (Belle Mead NJ). 2016;45:296-300.
RE-ENVISIONING THROWING PROGRAMS FOR BASEBALL PITCHERS 21
©The Internet Journal of Allied Health Sciences and Practice, 2025
50. Podesta L, Crow SA, Volkmer D, et al. Treatment of partial ulnar collateral ligament tears in the elbow with platelet-rich
plasma. Am J Sports Med 2013;41:1689-94.
51. Buckley PS, Morris ER, Robbins CM, et al. Variations in Blood Supply From Proximal to Distal in the Ulnar Collateral
Ligament of the Elbow: A Qualitative Descriptive Cadaveric Study. Am J Sports Med. 2019;47:1117-23.
52. Gentile P, Calabrese C, Angelis BD, et al. Impact of the Different Preparation Methods to Obtain Autologous Non-
Activated Platelet-Rich Plasma (A-PRP) and Activated Platelet-Rich Plasma (AA-PRP) in Plastic Surgery: Wound
Healing and Hair Regrowth Evaluation. International Journal of Molecular Sciences. 2020;21(2):431.
53. Scioli, M.G.; Bielli, A.; Gentile, P.; Cervelli, V.; Orlandi, A. Combined treatment with platelet-rich plasma and insulin
favours chondrogenic and osteogenic differentiation of human adipose-derived stem cells in three-dimensional
collagen scaffolds. J Tissue Eng Regen Med. 2017;11:2398–2410.
54. Cervelli, V.; Lucarini, L.; Spallone, D.; Palla, L.; Colicchia, G.M.; Gentile, P.; De Angelis, B. Use of platelet-rich plasma
and hyaluronic acid in the loss of substance with bone exposure. Adv Ski Wound Care. 2011;24:176–181.
55. Gentile, P.; Bottini, D.J.; Spallone, D.; Curcio, B.C.; Cervelli, V. Application of platelet-rich plasma in maxillofacial
surgery: Clinical evaluation. J Craniofacial Surg. 2010;2:900–904.
56. Frangiamore SJ, Lynch TS, Vaughn MD, et al. Magnetic Resonance Imaging Predictors of Failure in the Nonoperative
Management of Ulnar Collateral Ligament Injuries in Professional Baseball Pitchers. Am J Sports Med. 2017;45:1783-
9.
57. Kibler WB, Stone AV, Zacharias A, Grantham WJ, Sciascia AD. Management of scapular dyskinesis in overhead
athletes. Operative Techniques in Sports Medicine. 2021;29(1):150797. doi: 10.1016/j.otsm.2021.150797
58. Martin C, Kupla R, Delamarche P, et al. Professional tennis player’s serve: Correlation between segmental angular
momentums and ball velocity. Sports Biomech. 2013;12:2-14.
59. Nieminen H, Niemi J, Takala EP, et al. Load-sharing patterns in the shoulder during isometric flexion tasks. J Biomech.
1995;28:555-566.
60. Kibler WB, Sciascia AD, Dome DC. Evaluation of apparent and absolute supraspinatus strength in patients with
shoulder injury using scapular retraction test. Am J Sports Med. 2006;34:1643-1547.
61. Smith J, Dietrich CT, Kotajarvi BR, et al. The effect of scapula protraction on isometric shoulder rotation strength in
normal subjects. J Shoulder Elbow Surg. 2006;15:339-343.
62. McClure PW, Michener LA, Sennett BJ, et al. Direct 3-dimensional measurement of scapular kinematics during
dynamic movements in vivo. J Shoulder Elbow Surg. 2001;10:269-277.
63. Ludewig PM, Phadke V, Braman JP, et al. MOtion of the shoulder complex during multiplanar humeral elevation. J
Bone Joint Surg Am. 2009;91A:378-389..
64. Sheean AJ, Kibler WB, Conway J, et al. Posterior labral injury and glenohumeral instability in overhead athletes:
Current concepts for diagnosis and management. J Am Acad Orthop Surg. 2020;28;628-637.
65. Kibler WB, Sciascia A: The role of the scapula in preventing and treating shoulder instability. Knee Surg Arthrosc Sport
Traumatol. 2016;24:390-397.
66. Reuther KE, Thomas SJ, Tucker JJ, et al: Scapular dyskinesis is detrimental to shoulder tendon properties and joint
mechanics in a rat model. J Orthop Res. 2014;32:1436-1443.
67. Lawrence RL, Braman JP, LaPrade RF, et al: Comparison of 3-dimensional shoulder complex kinematics in individuals
with and without shoulder pain, part 1: Sternoclavicular, acromioclavicular, and scapulothoracic joints. J Orthop Sports
Phys Ther. 2014;44:636-645.
68. Lawrence RL, Braman JP, Staker JL, et al: Comparison of 3-dimensional shoulder complex kinematics in individuals
with and without shoulder pain, part 2: Glenohumeral joint. J Orthop Sports Phys Ther. 2014;44:646- 655.
69. Meyer KE, Saether EE, Soiney EK, et al: Three-dimensional scapular kinematics during the throwing motion. J Appl
Biomech. 2008;24:24-34.
70. Provencher MT, Makani A, McNeil JW, et al: The role of the scapula in throwing disorders. Sports Med Arthrosc Rev.
2014;22:80-87.
71. Fleisig GS, Andrews JR, Dillman CJ, et al: Kinetics of baseball pitching with implications about injury mechanisms. Am
J Sports Med. 1995;23:233- 239.
72. Fleisig GS, Barrentine SW, Zheng N, et al: Kinematic and kinetic comparison of baseball pitching among various levels
of development. J Biomech. 1999;32:1371-1375.
73. Yoshizaki K, Hamada J, Tamai K, et al: Analysis of the scapulohumeral rhythm and electromyography of the shoulder
muscles during elevation and lowering: Comparison of dominant and nondominant shoulders. J Shoulder Elbow Surg.
2009;18:756-763.
74. Ebaugh DD, McClure PW, Karduna AR: Three-dimensional scapulothoracic motion during active and passive arm
elevation. Clin Biomech. 2005;20:700-709.
RE-ENVISIONING THROWING PROGRAMS FOR BASEBALL PITCHERS 22
©The Internet Journal of Allied Health Sciences and Practice, 2025
75. Kibler WB, Sciascia A, Wilkes T: Scapular dyskinesis and its relation to shoulder injury. J Am Acad Orthop Surg.
2012;20:364-372.
76. Dvir Z, Berme N: The shoulder complex in elevation of the arm: A mechanism approach. J Biomech. 1978;11:219-225.
77. Provencher MT, Kirby H, McDonald LS, et al: Surgical release of the pectoralis minor tendon for scapular dyskinesia
and shoulder pain. Am J Sports Med. 2017;45:173-178.
78. Oliver GD, Weimar WH, Plummer HA: Gluteus medius and scapula muscle activations in youth baseball pitchers. J
Strength Cond Res. 2015;29:1494-1499.
79. Hirashima M, Kadota H, Sakurai S, et al: Sequential muscle activity and its functional role in the upper extremity and
trunk during overarm throwing. J Sport Sci. 2002;20:301-310.
80. Hirashima M, Yamane K, Nakamura Y, et al: Kinetic chain of overarm throwing in terms of joint rotations revealed by
induced acceleration analysis. J Biomech. 2008;41:2874-2883.
81. Leong HT, Tsui SSM, Ng GYF, et al: Reduction of the subacromial space in athletes with and without rotator cuff
tendinopathy and its association with the strength of scapular muscles. J Sci Med Sport. 2016;19:970-974.
82. Cools AM, Witvrouw EE, DeClercq GA, et al: Scapular muscle recruitment pattern: Trapezius muscle latency with and
without impingement symptoms. Am J Sports Med. 2003;31:542-549.
83. Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of
shoulder impingement. Phys Ther. 2000;80:276-291.
84. Joshi M, Thigpen CA, Bunn K, et al: Shoulder external rotation fatigue and scapular muscle activation and kinematics
in overhead athletes. J Ath Train. 2011;46:349-357.
85. Laudner KG, Stanek JM, Meister K. DIfferences in scapular upward rotation between baseball pitchers and position
players. Am J Sports Med. 2007;35:2091-2095.
86. Kibler WB, Kuhn JE, Wilk KE, et al. The disabled throwing shoulder-Spectrum of pathology: 10 year update.
Arthroscopy. 2013;29:141-161.
87. Paletta GA, Warner JJP, Warren RF, et al. Shoulder kinematics with two-plane x-ray evaluation in patients with anterior
instability or tator cuff tears. J Shoulder Elbow Surg. 1997;6:516-527.
88. Kibler WB, Sciascia AD. Kinetic chain contributions to elbow function and dysfunction in sports. Clin Sports Med.
2004;23:545-552.
89. Wilk WE, Macrina LC, Fleisig GS, et al. Deficits in glenohumeral passive range of motion increase risk of shoulder
injury in professional baseball pitchers: A prospective study. Am J Sports Med. 2015;43:2379-2385.
90. Erickson BJ, Nwachukwu BU, Rosas S, et al. Trends in medial ulnar collateral ligament reconstruction in the United
States: a retrospective review of a large private-payer database from 2007 to 2011. Am J Sports Med.
2015;43(7):1770-1774.
91. Hodgins JL, Vitale M, Arons RR, Ahmad CS. Epidemiology of medial ulnar collateral ligament reconstruction: a 10-year
study in New York State. Am J Sports Med. 2016;44(3):729-734.
92. Leland DP, Conte S, Flynn N, et al. Prevalence of medial ulnar collateral ligament surgery in 6135 current professional
baseball players: a 2018 update. Orthop J Sports Med. 2019;7(9):2325967119871442.
93. Fleisig GS, Andrews JR, Cutter GR, et al. Risk of serious injury for young baseball pitchers: a 10-year prospective
study. Am J Sports Med. 2011;39(2):253-257.
94. Lyman S, Fleisig GS, Andrews JR, Osinski ED. Effect of pitch type, pitch count, and pitching mechanics on risk of
elbow and shoulder pain in youth baseball pitchers. Am J Sports Med. 2002;30(4):463-468.
95. Olsen SJ, Fleisig GS, Dun S, Loftice J, Andrews JR. Risk factors for shoulder and elbow injuries in adolescent baseball
pitchers. Am J Sports Med. 2006;34(6):905-912.
96. Petty DH, Andrews JR, Fleisig GS, Cain EL. Ulnar collateral ligament reconstruction in high school baseball players:
clinical results and injury risk factors. Am J Sports Med. 2004;32(5):1158-1164.
97. Yang J, Mann BJ, Guettler JH, et al. Risk-prone pitching activities and injuries in youth baseball: findings from a
national sample. Am J Sports Med. 2014;42(6):1456-1463.
98. Dines JS, Frank JB, Akerman M, Yocum LA. Glenohumeral internal rotation deficits in baseball players with ulnar
collateral ligament insufficiency. Am J Sports Med. 2009;37:566-570.
99. Laudner KG, Myers JB, Pasquale MR, Bradley JP, Lephart SM. Scapular dysfunction in throwers with pathologic
internal impingement. J Orthop Sports Phys Ther. 2006;36:485-494.
100. Myers JB, Laudner KG, Pasquale MR, Bradley JP, Lephart SM. Glenohumeral range of motion deficits and posterior
shoulder tightness in throwers with pathologic internal impingement. Am J Sports Med. 2006;34:385-391.
101. Tyler TF, Nicholas SJ, Roy T, Gleim GW. Quantification of posterior capsule tightness and motion loss in patients with
shoulder impingement. Am J Sports Med. 2000;28:668-673.
RE-ENVISIONING THROWING PROGRAMS FOR BASEBALL PITCHERS 23
©The Internet Journal of Allied Health Sciences and Practice, 2025
102. Shanley E, Rauh MJ, Michener LA, Ellenbecker TS, Garrison JC, Thigpen CA. Shoulder range of motion measures as
risk factors for shoulder and elbow injuries in high school softball and baseball players. Am J Sports Med.
2011;39(9):1997-2006.
103. Wilk KE, Macrina LC, Fleisig GS, et al. Correlation of glenohumeral internal rotation deficit and total rotational motion to
shoulder injuries in professional baseball pitchers. Am J Sports Med. 2011;39:329-335.
104. Thigpen CA, Bailey LB, Kissenberth MJ, Noonan TJ, Hawkins RJ, Shanley E. Effectiveness of a preseason prevention
program on arm injury risk factors: An randomized control trial in adolescent pictures. Orthop J Sports Med.
2016;4(S3):2325967116S00066.
105. Crockett HC, Gross LB, Wilk KE, et al. Osseous adaptation and range of motion at the glenohumeral joint in
professional baseball pitchers. Am J Sports Med. 2002;30(1):20-28.
106. Chant CB, Litchfield R, Griffin S, Thain LM. Humeral head retroversion in competitive baseball players and its
relationship to glenohumeral rotation range of motion. J Orthop Sports Phys Ther. 2007;37(9):514-520.
doi:10.2519/jospt.2007.2449
107. Tokish JM, Curtin MS, Kim YK, Hawkins RJ, Torry MR. Glenohumeral internal rotation deficit in the asymptomatic
professional pitcher and its relationship to humeral retroversion. J Sports Sci Med. 2008;7:78-83.
108. Thomas SJ, Swanik CB, Higginson JS, et al. A bilateral comparison of posterior capsule thickness and its correlation
with glenohumeral range of motion and scapular upward rotation in collegiate baseball players. J Shoulder Elbow Surg.
2011;20(5):708-716. doi:10.1016/j.jse.2010.08.031
109. Thomas SJ, Swanik CB, Kaminski TW, et al. Humeral retroversion and its association with posterior capsule thickness
in collegiate baseball players. J Shoulder Elbow Surg. 2012;21(7):910-916. doi:10.1016/j.jse.2011.05.028
110. Noonan TJ, Shanley E, Bailey LB, et al. Professional pitchers with glenohumeral internal rotation deficit (GIRD) display
greater humeral retrotorsion than pitchers without GIRD. Am J Sports Med. 2015;43(6):1448-1454.
doi:10.1177/0363546515575020
111. Hibberd EE, Oyama S, Myers JB. Increase in humeral retrotorsion accounts for age-related increase in glenohumeral
internal rotation deficit in youth and adolescent baseball players. Am J Sports Med. 2014;42(4):851-858.
doi:10.1177/0363546513519325
112. McElheny K, Sgroi T, Carr JB. Efficacy of arm care programs for injury prevention. Current Reviews in Musculoskeletal
Medicine. 2021;14:160-167.
113. Camp CL, Jensen AR, Leland DP, Flynn N, Lahti J, Conte S. Players’ perspectives on successfully returning to
professional baseball after medial ulnar collateral ligament reconstruction. Journal of Shoulder and Elbow Surgery.
2021;30:e245-e250.
114. Sgroi TA, Zajac JM. Return to throwing after shoulder or elbow injury. Current Reviews in Musculoskeletal Medicine.
2018;11:12-18.
115. Wilk KE, Voight ML, Keirns MA, Gambetta V, Andrews JR, Dillman CJ. Stretch-shortening drills for the upper
extremities: Theory and clinical application. J Orthop Sports Phys Ther. 1993;17(5):225-39.
116. Anderson MJ, Crockatt WK, Mueller JD, et al. Return-to-competition after ulnar collateral ligament reconstruction: A
systematic and meta-analysis. Am J Sports Med. 2022;50(4):1157-1165.
117. Hintz C, Colon D, Honnette D, et al. Individualizing the throwing progression following injury in baseball pitchers: The
past, present, and future. Current Reviews in Musculoskeletal Medicine. 2022;15:561-569.
118. Hannon J, Garrison JC, Conway J. Lower extremity balance is improved at time of return to throwing in baseball
players after an ulnar collateral ligament reconstruction when compared to pre-operative measurements. The
International Journal of Sports Physical Therapy. 2014;9(3):356-362.
119. Jeffries AC, Marcora SM, Coutts AJ, Wallace L, McCall A, Impellizzeri FM. Development of a revised conceptual
framework of physical training for use in research and practice. Sports Med. 2021;52(4):709–24.
120. Axe MJ, Snyder-Mackler L, Konin JG, Strube MJ. Development of a distance-based interval throwing program for Little
League-aged athletes. Am J Sports Med. 1996;24(5):594–602.
121. Axe M, Hurd W, Snyder-Mackler L. Data-based interval throwing programs for baseball players. Sports Health.
2009;1(2):145–53.
122. Melugin HP, Larson DR, Fleisig GS, et al. Baseball pitchers’ perceived effort does not match actual measured effort
during a structured long-toss throwing program. The American Journal of Sports Medicine. 2019;47(8):1949-1954.
123. Ardern CL, Glasgow P, Schneiders A, Witvrouw E, Clarsen B, Cools A, Gojanovic B, Griffin S, Khan KM, Moksnes H,
Mutch SA, Phillips N, Reurink G, Sadler R, Grävare Silbernagel K, Thorborg K, Wangensteen A, Wilk KE, Bizzini M.
2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. Br J
Sports Med. 2016;50(14):853–64.
124. Thorpe RT, Atkinson G, Drust B, Gregson W. Monitoring fatigue status in elite team-sport athletes: implications for
practice. Int J Sports Physiol Perform. 2017;12(Suppl 2):S227–S234.
RE-ENVISIONING THROWING PROGRAMS FOR BASEBALL PITCHERS 24
©The Internet Journal of Allied Health Sciences and Practice, 2025
125. Saw AE, Kellmann M, Main LC, Gastin PB. Athlete self-report measures in research and practice: considerations for
the discerning reader and fastidious practitioner. Int J Sports Physiol Perform. 2017;12(Suppl 2):S2127–S35.
126. Hintz C, Colon D, Honnette D, et al. Individualizing the throwing progression following injury in baseball pitchers: The
past, present, and future. Current Reviews in Musculoskeletal Medicine. 2022;15:561-569.
127. Sporer BC, Windt J. Integrated performance support: facilitating effective and collaborative performance teams. Br J
Sports Med. 2018;52(16):1014–5.
128. Aguinaldo A, Escamilla R. Segmental power analysis of sequential body motion and elbow valgus loading during
baseball pitching: comparison between professional and high school baseball players. Orthop J Sports Med.
2019;7(2):2325967119827924.
129. Leafblad ND, Larson DR, Fleisig GS, Conte S, Fealy SA, Dines JS, D’Angelo J, Camp CL. Variability in baseball
throwing metrics during a structured long-toss program: does one size fit all or should programs be individualized?
Sports Health. 2019;11(6):535–42.
130. Lizzio VA, Smith DG, Jildeh TR, Gulledge CM, Swantek AJ, Stephens JP, et al. Importance of radar gun inclusion
during return-to-throwing rehabilitation following ulnar collateral ligament reconstruction in baseball pitchers: a
simulation study. J Shoulder Elbow Surg. 2020;29(3):587–92.
131. Slenker NR, Limpisvasti O, Mohr K, Aguinaldo A, Elattrache NS. Biomechanical comparison of the interval throwing
program and baseball pitching: upper extremity loads in training and rehabilitation. Am J Sports Med.
2014;42(5):1226–32.
132. Koh JL, Schafer MF, Keuter G, Hsu JE. Ulnar collateral ligament reconstruction in elite throwing athletes. Arthroscopy.
2006;22(11):1187-1191.
133. Kalkhoven JT, Watsford ML, Coutts AJ, Edwards WB, Impellizzeri FM. Training load and injury: causal pathways and
future directions. Sports Med. 2021;51(6):1137–50.
134. Hulin BT, Gabbett TJ, Lawson DW, et al. The acute:chronic workload ratio predicts injury: High chronic workload may
decrease injury risk in elite rugby league players. British Journal of Sports Medicine. 2016;50:231-236.
135. Griffin A, Kenny IC, Comyns TM, Lyons M. The association between the acute:chronic workload ratio and injury and its
application in team sports: A systematic review. Sport Medicine. 50;561-580.
136. Chalmers PN, English J, Cushman DM, Zhang C, Presson AP, Yoon S, et al. The ulnar collateral ligament responds to
stress in professional pitchers. J Shoulder Elbow Surg. 2021;30(3):495–503.
137. Griffith TB, Conte S, Poulis GC, Diamond A, D’Angelo J, Camp CL. Correlation of rehabilitation and throwing program
milestones with outcomes after ulnar collateral ligament reconstruction: An analysis of 717 professional baseball
pitchers. The American Journal of Sports Medicine. 2022;50(7):1990-1996.
138. Staunton CA, Abt G, Weaving D, Wundersitz DWT. Misuse of the term 'load' in sport and exercise science. J Sci Med
Sport. 2021;25(5):439–44.
139. Carr JB, Manzi JE, Estrada J, Dowling B, McElheny KL, Dines JS. Interval throwing programs at distances beyond 150
feet can be equivalent to pitching over five innings. Arthroscopy: The Journal of Arthroscopic and Related Surgery.
2022;38(9):2638-2646.
140. Melugin HP, Larson DR, Fleisig GS, et al. Baseball pitchers’ perceived effort does not match actual measured effort
during a structured long-toss throwing program. The American Journal of Sports Medicine. 2019;47(8):1949-1954.
141. Hedt CA, Holland SB, Lambert BS, Harris JD, McCulloch PC. The utilization of interval throwing programs in the
physical therapy setting: A cross-sectional survey. Journal of Sport Rehabilitation. 2019;28:421-431.
142. Gennarelli SM, Brown SM, Mulcahey MK. Psychosocial interventions help facilitate recovery following musculoskeletal
sports injuries: a systematic review. The Physician and Sportsmedicine. 2020;48(4):370-377. Doi:
10.1080/00913847.2020.1744486
143. Chan DKC, Lee ASY, Hagger MS, Mok KM, Yung PS. Social psychological aspects of ACL injury prevention and
rehabilitation: An integrated model for behavioral adherence. Asia-Pacific Journal of Sports Medicine, Arthroscopy,
Rehabilitation, and Technology. 2017;10:17-20. Doi: 10.1016/j.asmart.2017.10.001
144. Weinberg RS. Goal Setting in Sport and Exercise: Research to Practice. In J. Van Raalte & B. Brewer (Eds), Exploring
Sport and Exercise Psychology. 3rd ed. American Psychological Association; 2014:33-54. Doi: 10.1037/14251-003
145. Locke EA, Latham GP. Building a Practically Useful Theory of Goal Setting and Task Motivation: A 35- year odyssey.
American Psychologist. 2002;57(9):705- 717. Doi: 10.1037//0003-066X.57.9.705
146. Schwab Reese LM, Pittsinger R, Yang J. Effectiveness of psychological intervention following sport injury. Journal of
Sport and Health Science. 2012;1:71-79. Doi:10.1016/j.jshs.2012.06.003
147. Coronado RA, Sterling EK, Fenster DE, et al. Cognitive-behavioral-based physical therapy to enhance return to sport
after anterior cruciate ligament reconstruction: An open pilot study. Physical Therapy in Sport. 2020;42:82 – 90. Doi:
10.106/j.ptsp.2020.01.004
RE-ENVISIONING THROWING PROGRAMS FOR BASEBALL PITCHERS 25
©The Internet Journal of Allied Health Sciences and Practice, 2025
148. Daley MM, Griffith K, Milewski MD, Christino MA. The Mental Side of the Injured Athlete. Journal of the American
Academy of Orthopedic surgeons. 2020;29(12):499 – 506. Doi: 10.5.5435/JAAOS-D-20-00974
149. Evans L, Hardy L. Injury Rehabilitation: A Goal-Setting Intervention Study. Research Quarterly for Exercise and Sport.
2002;43(3):310 – 319.
150. Arvinen-Barrow M, Hemmings B. Goal Setting in Sport Injury Rehabilitation. In M. Arvinen-Barrow & N. Walker (Eds),
The Psychology of Sport Injury and Rehabilitation. 1st edition. Routledge; 2013:56-70.
151. Scherzer CB, Brewer BW, Cornelius AE, et al. Psychological Skills and Adherence to Rehabilitation after
Reconstruction of the Anterior Cruciate Ligament. Journal of Sport Rehabilitation. 2001;10(3):165-172.
Doi:10.1123/jsr.10.3.165
152. Theodorakis Y, Beneca A, Malliou P, Goudas M. Examining psychological factors during injury rehabilitation. Journal of
Sport Rehabilitation. 1997;6:355- 363.
153. Podlog L, Eklund RC. Returning to competition after a serious injury: the role of self-determination. Journal of Sports
Science. 2010;28(3):819- 831. Doi: 10.1080/02640411003792729
154. Arden CL, Taylor NF, Feller JA, Webster KE. A systematic review of the psychological factors associated with returning
to sport following injury. British Journal of Sports Medicine. 2013;47(17):1120 – 1126. Doi: 10.1136/bjsports-2012-
091203.
155. Ntoumanis N, Ng JYY, Prestwich A, et al. A meta-analysis of self-determination theory-informed intervention studies in
the health domain: effects on motivation, health behavior, physical, and psychological health. Health Psychology
Review. 2021;15(2):214 – 244. Doi: 10.1080/17437199.2020.1718529
156. Yung KK, Ardern CL, Serpiello FR, Robertson S. Characteristics of complex systems in sports injury rehabilitation:
examples and implications for practice. Sports Med Open. 2022;8(1):24.
157. Carr J, Manzi J, Estrada J, Dowling B, McElheny K, Dines J. Comparison of elbow varus torque during interval
throwing programs and gameday pitching in high school baseball pitchers. The Orthopaedic Journal of Sports
Medicine. 2021;9(10)(suppl 5).
158. Saw AE, Main LC, Gastin PB. Monitoring the athlete training response: subjective self-reported measures trump
commonly used objective measures: a systematic review. Br J Sports Med. 2016;50(5):281–91.
159. Buckthorpe M, Frizziero A, Roi GS. Update on functional recovery process for the injured athlete: return to sport
continuum redefined. Br J Sports Med. 2019;53(5):265–7.
160. Matsuo T. Comparison of kinematic and temporal parameters between pitch velocity. J Appl Biomech. 2001;17:1-13.
161. Camp CL, Tubbs TG, Fleisig GS, et al. The relationship of throwing arm mechanics and elbow varus torque: Within-
subject variation for professional baseball pitchers across 82,000 throwers. The American Journal of Sports Medicine.
2017;45(13):3030-3035.
162. Stone AV, Mannava S, Patel A, Marquez-Lara A, Freehill MT. Defining the long-toss: A professional baseball
epidemiological study. The Orthopaedic Journal of Sports Medicine. 2017;5(2):2325967116686773.
163. Smith MV, Bernholt DL. Ulnar collateral ligament injury in the elbow: Current trends for treatment. Annals of Joint.
2020;5:15.
164. Udall JH, Fitzpatrick MJ, McGarry MH, et al. Effects of flexor-pronator muscle loading on valgus stability of the elbow
with an intact, stretched, and resected medial ulnar collateral ligament. J Shoulder Elbow Surg. 2009;18:773-8.
165. Smucny M, Westermann RW, Winters M, et al. Non-operative management of ulnar collateral ligament injuries in the
throwing athlete. Phys Sportsmed 2017;45:234-8.
166. Dines JS, Williams PN, ElAttrache N, et al. Platelet-Rich Plasma Can Be Used to Successfully Treat Elbow Ulnar
Collateral Ligament Insufficiency in High-Level Throwers. Am J Orthop (Belle Mead NJ). 2016;45:296-300.
167. Podesta L, Crow SA, Volkmer D, et al. Treatment of partial ulnar collateral ligament tears in the elbow with platelet-rich
plasma. Am J Sports Med 2013;41:1689-94.
168. Buckley PS, Morris ER, Robbins CM, et al. Variations in Blood Supply From Proximal to Distal in the Ulnar Collateral
Ligament of the Elbow: A Qualitative Descriptive Cadaveric Study. Am J Sports Med. 2019;47:1117-23.
