Pain Site vs. Pain Source: 3 Ways the Lower Half Causes Medial Elbow Pain

By Nunzio Signore (BA, CSCS, CPT, NASM, FMS)

Elbow Pain Top

In Part 2 of this series on pain site vs. pain source (click here for Part 1), we’ll look at medial elbow pain, how it’s not always originating at the arm (or from the upper half for that matter).

A recent study in in the (Journal of Arthroscopy) noted 31% of pitchers up to the age of 22 have experienced an arm injury, 30% of the players up to the age of 12 reported episodes of elbow pain (The Physician and Sports Medicine), and 61% of all minor league players with TJ surgery had it done during high school or college.  Just to give you an idea of the severity of the situation, here is a graph showing the rise in Tommy John surgeries performed each year by Dr. James Andrews (courtesy of Mike Reinold):

TJ Chart

Having said all that, there are many factors involved that can contribute to medial elbow pain and/or injury including, among others:

  • Overuse (innings/games pitched)
  • Loss of strength, especially in-season (click here)
  • Improperly managed weighted ball programs (wrong dosage)
  • Poor pitching mechanics

In this article, we’re going to be talking about the latter, poor pitching mechanics, and more specifically how poor lower half mechanics (pain source) can present itself distally in the body affecting the medial elbow (pain site).  The three lower half issues affecting the elbow we are going to review today are as follows:

  • Closed Landing at Foot Strike
  • Knee Angle at Ball Release
  • Lack of Pelvic/Glute Engagement

Closed Landing at Foot Strike – When the lead foot lands closed (see photo below), the delivery begins to unfold early, causing the arm to arrive “late” to the party. This is sometimes called “forearm flyout” which puts undue stress on the medial elbow. Many pitching coaches will focus on the late arm (site) instead of the early foot strike (source).

Closed Landing 1


Closed Landing 2


 Knee Angle at Ball Release – If the knee angle at foot strike is less than optimal, this can create issues further up the chain affecting the arm. By the same token, if the knee angle at ball release is not sufficient enough, the front hip will lock out, negatively affecting rotation during the deceleration phase (finish). If the body stops rotating, the arm will keep going and straighten out, putting added stress on the medial elbow due to rapid elbow extension. The following tutorial below goes into more depth:

(Knee Angle / Trunk Tilt)

Lack of Pelvic / Glute Engagement – This one falls into the “overuse” category as well. 50% of power comes from the lower half. If the athlete does not “load while moving forward”, the glutes will not engage. This forces the upper body to repeatedly do all the work, which over time places an unnecessary amount of stress on the upper body, particularly the medial and lateral elbow.

Note: Loading without moving forward is pointless as it causes the athlete to “stay back” using the glute load as a means of counter balance for a “runaway” front leg instead of power for coming down the mound and/or leverage to help stabilize the pelvis at first foot strike.

Pelvic 1

(Zack Grienke – Efficient Glute Load)

The image below may LOOK like a glute load but it’s just another energy leak.  Note the bent “quad dominant” rear leg.

Pelvic 2

(Bent Knee)

Here at RPP, with the help of our slo-motion 4-camera video system we break down pitching delivery into its many components.  From there we can prescribe throwing correctives that can address many of these issues. If you would like more info about our Pitchers Rx Program click here.

See ya’ in the gym…


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