Baseball players and other athletes could benefit from reduced future injury risk with a sports rehabilitation program designed to address inefficient movement patterns.

Ellen Shanley, PhD, PT, OCS

Many sports require a series of complex movements and force from an athlete for successful participation, which may lead to overuse injuries depending on multiple factors. For instance, the generation and transfer of force relies upon efficient movement control and sequencing during activities, such as pitching a baseball or softball. When the athlete experiences inefficiencies in the sport movement patterns, those inefficiencies can shift stress to other body segments—which can be a precursor to injury.1-3 A history of injury has also been identified as a significant risk factor in the development of additional overuse injuries in numerous sports.4-6 It has been theorized that prior injury increases an athlete’s risk of re-injury based on inadequate attention to address deficits, such as range of motion loss,7 poor balance,8 reduced dynamic postural control,9 and inadequate fitness.

ATI Physical Therapy’s recent work confirms that even after initial recovery and return to sport, athletes demonstrated increased risk for concussion (4.7; 95% CI = 4.2-5.2) and arm injuries (2.6; 95% CI: 1.2, 5.6) in a variety of sports. Together, the evidence suggests that targeting athletes with a specialized rehabilitation program designed to address inefficient movement patterns might reduce their elevated risk for future injuries.

Recovery and Injury Prevention

For clinicians, these types of findings should be a reminder that helping athletes return to activity is facilitated through a focused rehabilitation program promoting recovery and subsequent injury prevention. The care plan should include a progressive, multi-planar functional assessment of motion, muscle performance, balance, and proprioception. It is also beneficial to monitor athlete progression using clinical measures and functional criteria to determine readiness to return to work, community, and home activities. It is valuable for athletes to have access to follow-up after discharge including in-person screening when necessary to help create the safest environment to stay active while avoiding additional injury.

A successful sports rehabilitation program within a community requires periodic visits with athletes and teams to determine current and previous athlete injury. These visits allow screening for health changes or potential problems that help athletes become aware of their risk for injury. General screening programs can be adapted to the sport, age range, physical maturity, and position of athletes. Then, exercise programs and educational information can be provided to address areas of concern such as flexibility, muscle performance, or balance.

Not all injuries are preventable, and after an injury occurs early rehabilitation should focus on protecting the healing tissue and resolving an athlete’s specific impairments. Prevention of future injury, a key component of rehabilitation, requires the therapist to highlight and help modify risk factors for future injury. The athlete and their impairments can then be matched to the proper treatment at the optimal time to expedite a safe and sustainable return to health. 

Tools of the Trade

To highlight integration of the types of interventions that are important to rehabilitate injured athletes and decrease the risk of further injury, one example is the case of a baseball player with a high ankle sprain. Restoring mobility and strength should be an early emphasis while sport-specific balance and coordination are equally paramount to an eventual safe return to baseball. 

Throughout this process, clinicians can use a variety of tools to help with mobility, stabilization, and strength such as medicine balls, appropriate weights, exercise bands, and equipment. As the player’s rehabilitation progresses and early deficits resolve, the therapist can concentrate on establishing the proper kinetic chain process to allow the athlete to successfully throw, field, hit, run, and slide during baseball activities. 

Reach Testing and Training

Anterior reach testing and training (part of the Y balance test) is an example of an early balance activity that has helped athletes train the movement pattern required for throwing and fielding a baseball. Using this activity as part of training and assessment of athlete balance and function helps to compare side-to-side reach distance between legs within and between sessions. The within-session measurements help clinicians to gauge the athlete’s balance and endurance as they participate in fatiguing activities. The between-session performance measures the athlete’s progression of single-leg balance during their recovery. 

The baseball athlete’s primary position might dictate the necessity of adding serial side-to-side measurements of the remaining components of the Y balance test (posterior medial and lateral reach). Middle infielders or outfielders may benefit from these portions of the test based on their individual needs and movement patterns. 

Functional Training

As the baseball athlete advances through therapy, functional training that requires recognition of a play, a need to change direction quickly, and to maintain balance during unanticipated movements is critical to returning safely to high levels of sport. These skills represent challenges faced during a baseball game. 

Consider that a Major League Baseball batter has an average of 25 milliseconds to decide whether to swing at or evade a pitch traveling 90 mph from the pitcher’s mound. The middle infielder needing to catch a ball, tag the base, and avoid the sliding runner to turn a double play must be able to anticipate and react to this situation based on visual or auditory cues and move accordingly. As such, these demands could expose the unprepared athlete to a high risk of a second injury. 

Additional Sport-Specific Drills

The incorporation of additional training throughout the middle and end of rehabilitation is seen as an opportunity to ensure that the injured athlete is prepared for these challenges. Neuromuscular reactive agility training helps prepare an athlete to protect themselves from injury during competition. This type of training allows monitoring of the athlete’s time to react to a visual, auditory, or movement cue and time to change direction or activities based on these specific drills. As the athlete recovers, the time until cue recognition or change in movement will normalize and tasks should become more complex or performed at the end of a rehabilitation session. The addition of such drills will create an opportunity to establish proper fitness, balance, and movement patterns to allow the athlete to successfully throw, field, hit, run, and slide during baseball activities and return to participation without an elevated risk for injury. 

By identifying key areas of improvement that are sport-specific, applying rehabilitation techniques to improve injury and prevent re-injury, and including drills that are tailored to an athlete’s sport and position, clinicians can develop a program that is not only successful for patients, but also provides a higher level of service to the local community.

Ellen Shanley, PhD, PT, OCS, is a clinical research scientist for ATI and serves as the Director of Athletic Injury Research, Pre­vention, and Education for the South Carolina Center for Rehabilitation and Reconstruction Sciences. She also serves as faculty at the University of South Carolina in the School of Public Health, Clemson University School of Bioengineering and Rocky Mountain University of Health Professions PhD program. She functions as Senior Faculty in an APTA-credentialed sports residency and is a co-founder of the APTA-credentialed upper extremity fellowship for ATI and the Kansas City Royals. She has previously and continues to mentor residents, fellows, and PhD students.

Shanley specializes in the treatment of patients with upper extremity injuries. She serves on the APTA orthopedic sections research committee and provides grant and abstract reviews for the APTA sports section. As a mem­ber of the American Society of Shoulder and Elbow Therapists (ASSET), Shanley has served as the Education Chair and is the Societies President-Elect. She has been awarded the APTA’s excellence in research award and ASSET’s Founders Award. 

Shanley’s research focuses on prevention and treatment of athletic injuries and is funded by Major League Baseball, the National Athletic Trainers Research and Education Foundation, and the APTA Sports Section. She has previously assisted with research at the NFL combine and continues to work with the Colorado Rockies. Shanley has published and/or presented on epidemiologic perspectives, identification and modification of risk factors, rehabilitation and returning youth through professional athletes to play. She has lectured regionally, nationally, and internationally on topics including treatment and out­comes of patients receiving total shoulder arthroplasty, hip arthroscopy, and prevention and treatment of athletic injuries. 


1. Kibler B, A S. Kinetic chain contributions to elbow function and dysfunction in sports. Clinics in Sports Medicine2004;23(4):545-52.

2. Kibler WB. Closed kinetic chain rehabilitation for sports injuries. Physical Medicine and Rehabilitation Clinics of North America 2000;11(2):369-84.

3. Kibler WB. Rehabilitation of rotator cuff tendinopathy. Clinics in sports medicine 2003;22(4):837-47.

4. Van Mechelen W, Twisk J, Molendijk A, et al. Subject-related risk factors for sports injuries: a 1-yr prospective study in young adults. Medicine and science in sports and exercise 1996;28(9):1171-9. [published Online First: 1996/09/01]

5. Kucera KL, Marshall SW, Kirkendall DT, et al. Injury history as a risk factor for incident injury in youth soccer. British journal of sports medicine 2005;39(7):462. doi: 10.1136/bjsm.2004.013672

6. Emery CA, Meeuwisse WH, McAllister JR. Survey of sport participation and sport injur y in Calagary and area high schools. Clin in Sports Med 2006;16:20-26.

7. Shitara H, Tajika T, Kuboi T, et al. Ankle dorsiflexion deficit in the back leg is a risk factor for shoulder and elbow injuries in young baseball players. Sci Rep 2021;11(1):5500. doi: 10.1038/s41598-021-85079-8 [published Online First: 2021/03/23]

8. Arnold BL, De La Motte S, Linens S, et al. Ankle instability is associated with balance impairments: a meta-analysis. Med Sci Sports Exerc 2009;41(5):1048-62. doi: 10.1249/MSS.0b013e318192d044 [published Online First: 2009/04/07]

9. Garrison JC, Arnold A, Macko M, et al. Baseball Players Diagnosed With Ulnar Collateral Ligament Tears Demonstrate Decreased Balance Compared to Healthy Controls. JOSPT 2013;43(10):752-58. doi: doi:10.2519/jospt.2013.468