The final phase, the follow-through phase, starts at shoulder maximum internal rotation and ends when the arm assumes a balanced position across the trunk. Lower extremity extension and trunk flexion help distribute forces throughout the body, taking stress away from the throwing arm. The posterior shoulder musculature and scapular protractors contribute to continued deceleration and muscle firing returns to resting levels. This complex motion of throwing fueled by the kinetic chain lasts less than 2 seconds and can result in ball release speeds as high as 100 miles per hour.3,4
Return to Throwing: Principles
Nonoperative and postoperative rehabilitation programs allow restoration of motion, strength, static and dynamic stability, and neuromuscular control. The initiation of an interval throwing program (ITP) is based on the assumption that tissue healing is complete and a complete physical examination has been conducted to the treating physician’s approval.11 An ITP progressively applies forces along the kinetic chain in a controlled manner through graduated throwing distances, while minimizing the risk of re-injury.
Reinold and colleagues12 described guidelines that were used in the development of the ITP.12 These factors include: (1) The act of throwing a baseball involves the transfer of energy from the feet up to the hand and therefore careful attention must be paid along the entire kinetic chain; (2) gradual progression of interval throwing decreases the chance for re-injury; (3) proper warm-up; and (4) proper throwing mechanics minimizes the chance of re-injury.
Variability. Unlike traditional rehabilitation programs that advance an athlete based on a specific timetable, the ITP requires that each level or phase to be completed pain-free or without complications prior to starting the next level. Therefore, an ITP can be used for overhead athletes of varying skill levels because progression will be different from one athlete to another. It is also important to have the athlete adhere strictly to the program, as over-eagerness to complete the ITP as quickly as possible can increase the chance of re-injury and thus slow the rehabilitation process.12
Warm-up. An adequate warm-up is recommended prior to initiating ITP. An athlete should jog or cycle to develop a light sweat and then progress to stretching and flexibility exercises. As emphasized before, throwing involves nearly all the muscles in the body. Therefore, all muscle groups should be stretched beginning with the legs and working distally along the kinetic chain.
Mechanics. Analysis, correction, and maintenance of proper throwing mechanics is essential throughout the early phases of rehabilitation and ITP. Improper pitching mechanics places increased stress on the throwing arm, potentially leading to re-injury. Therefore, it would be valuable to have a pitching coach available to emphasize proper mechanics throughout the rehabilitation process.
The Interval Throwing Program
For a PDF patient handout that summarizes the phases of this program, see Appendix 1.
Phase 1. We have adopted the ITP as described by Reinold and colleagues.12 Phase begins with the overhead athlete throwing on flat ground. He or she begins tossing from 45 feet and gradually progresses to 60, 90, 120, 150, and 180 feet.
As discussed earlier, it is critical to use proper mechanics throughout the ITP. The “crow hop” method simulates a throwing act and helps maintain proper pitching mechanics. Crow hop has 3 components: hop, skip, and throw. Using this technique, the pitcher begins warm-up throws at a comfortable distance (generally 30 feet) and then progresses to the distance as indicated on the ITP. The athlete will then need to perform each step 2 times, with 1 day of rest between steps, before advancing to the next step. The ball should be thrown with an arc and have only enough momentum to reach the desired distance.
For example, Step 1 calls for the athlete to perform 2 sets of 25 throws at 45 feet, with adequate rest (5 minutes) between sets. This step will be repeated following 1 day of rest. If the athlete demonstrates the ability to throw at the prescribed distance without pain, he or she can progress to Step 2, which calls for 3 sets of 25 throws at 45 feet. If pain is present at any step, the thrower returns to the previous asymptomatic step and can progress once he is pain-free.
Positional players are instructed to complete Phase 1 prior to starting position-specific drills. Pitchers, on the other hand, are instructed to stop once they reach and complete 120 feet. They will then progress to tossing at progressive distances of 60, 90, and 120 feet, followed by throwing at 60 feet 6 inches with normal pitching mechanics, initiating straight line throws with little to no arc.