Latissimus Tears: The Newest Injury for Throwing Athletes (Part II)

Just when you thought rehabbing pitchers was hard enough, a new injury has emerged in the throwing population

If you haven’t read Part I of our series, please check it out now. In part I we discussed anatomy, how the lats are in involved with pitching, reasons for the increase in lat injury frequency, and a brief surgical review.

For Part II, we are discussing common compensations we see in the “lat dominant” population and demonstrate a few examples of our favorite functional exercises to retrain this dominance with video demonstration by OSSPT patient and San Francisco Giants prospect, Caleb Simpson.

As previously mentioned, the lats have multiple attachment sites, spanning across several joints in the body, including the thoracic and lumbar spine, pelvis, ribs, scapula, and humerus. Because of all these various attachment sites, the lats have a major influence on posture, breathing, pelvic control, scapular mobility, and glenohumeral positioning. When the lats are working properly, they are crucial in power development with throwing; however, when the lats become too dominant, they are at risk of injury.

Although we are big believers of implementing deadlifting, horizontal/vertical pulling, and carrying into an athletes plan of care, we need to make sure the lats do not become the dominant muscle with all lifts for the throwing athlete.  When presented with a task that is too demanding for the throwing athlete, he/she will revert to over-utilizing the dominant muscles.  Our job as physical therapists is to, first identify these compensations, then educate and correct the athlete of proper movement patterning.  We must prescribe the athlete with exercises that are challenging, but also achievable.

To assist with better identifying when the lats may have become too dominant, we have listed some common compensation patterns to look for.

Common “Lat Dominant” Compensations

1. Excessive lumbar extension/anterior pelvic tilt: with attachments anterior pelvic tiltto the thoracolumbar fascia, spine, and pelvis, overly dominant lats will often lead to excessive lumbar extension and an anteriorly pelvic tilted position.  Overly-dominant muscles often lead to shortened muscles so we need to incorporate exercises that force the lats to work in an eccentric, lengthened position while maintaining a neutral spine.

2. Faulty breathing mechanics: most of our patients, particularly our athletes, have poor diaphragmatic breathing and often over recruit the accessory respiratory muscles, including the lats.  Many of the accessory respiratory muscles further pull the body into a lumbar extended, anteriorly pelvic tilted position. At rest, we breathe approx. 15,000-20,000x/day. If we are constantly breathing improperly, the lats are living in faulty, shortened positions.  We spend a lot of time teaching proper diaphragmatic breathing to our throwing athletes and incorporate diaphragmatic breathing into our exercises when possible.

3. Rib flaring: the first two compensations we discussed will often lead to rib flaring, so if we correct the excessive lumbar lordosis/anterior pelvic tilt and faulty breathing mechanics, the rib flare may resolve; however, a rib flarerib flare can also develop due to weakness of the anterior core.  With our throwing athletes, we must incorporate anterior core control exercises while in an overhead position. This will ensure our pitchers can successfully control the rib cage, which is vital to ensure proper scapular position as well.

4. Shoulders falling into IR and/or adducted positions: the most common technique used to identify this compensation pattern is the prone horizontal abduction exercise.  Instead of the shoulder remaining at 90 deg. during the arm raise, the overly dominant lat will pull the arm down toward the hip (as you can see in the picture below). In early stages of rehab, teaching and performing this exercise correctly can be an appropriate intervention to reduce the lat dominance and improve mid trap and rhomboid activation with this movement.

Lat dominant prone T5. Insufficient scapular elevation/upward rotation: due to the lats attachment to the inferior aspect of the scapula, “dominant lats” can lead to depressed scapula, or at the minimum, dominant lats can prevent proper scapular elevation/upward rotation with overhead movements. For the throwing athlete, a lack of proper scapular control and movement will lead to impaired glenohumeral joint congruency and contribute to rotator cuff/labral pathology.

Exercise Examples

1.Plank –> Downward Dogan excellent upper extremity closed chain movement that promotes proper scapular upward rotation and requires anterior core control, while putting the lat in a lengthened position. We cue the athlete to drive thru the palms, maintain a neutral spine, and bring the hips to the sky. We will use this exercise as a primer before introducing higher level overhead movements.

2. MedBall Lat Pullovers: this exercise forces the athlete to maintain a neutral spine, not allow rib flaring while controlling the medball overhead, and teaches proper eccentric lat control. We will often incorporate diaphragmatic breathing techniques while in the overhead position as well. Just like our previous exercise, this can be another primer movement.

3. Wall Angels: this exercise is an excellent choice for the general population to address common postural dysfunctions including excessive lumbar lordosis, anterior pelvic tilt, increased thoracic kyphosis, rounded shoulders, and forward head positioning. To perform correctly, the athlete cannot allow rib flaring either.

4. Half Kneeling S.A. 90-90 Row-ER-Press: as we progress through our exercise examples, we are gradually increasing loads as well. With this exercise, we continue to demand proper core control, emphasized by adding an unstable surface via the Dynadisc for the R knee. This exercise also demands proper posterior rotator cuff activation as we cue the athlete to drive his fist straight to the sky during the press movement. To better replicate the pitching demands and mimic a glove side pulling that many pitching coaches instruct with an isometric glove side row.

5. Unilateral Overhead KB Marches: this exercise is a great stability based exercise in multiple planes of movement, particularly when we add the band resistance as well. The big thing to watch for is excessive lumbar extension, rib flare, pelvic drop, or the athlete not keeping the KB shoulder in full flexion with slight shoulder ER. We cue them to drive the KB to the sky w/o allowing the shoulder to shrug. As we can see in the video below, Caleb is having some difficulty with maintaining extended elbow position and he is allowing the shoulder to rotate internally.

6. Tall Kneeling Halos: our last exercise may  look easy from the surface, but halos will reveal compensations really quickly. This exercise demands excellent core stability and a combination of excellent shoulder stability and mobility.

The lats are important muscles for the throwing athlete and it’s vital that we identify and correct common movement dysfunctions and implement appropriate exercises to re-train these faulty movement patterns.

I hope you enjoyed our 2 part blog post. I wanted to provide a quick shout out to Mike Reinold and Eric Cressey.  I was introduced to these two guys eight years ago while working with the Atlanta Braves and I have attempted to read everything they have produced since that time and they are two of the biggest influences in my professional career. Both guys put out great material on a daily basis and so much of how I treat our baseball players is either directly or indirectly influenced by them, including this blog post. I want to say a big thank you to Mike and Eric for how much they have helped, not only me, but the medical and performance profession as a whole.

 

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