Is There A Fix for Dallas Keuchel?

Is that not the question all of the baseball community is asking? Can last year's Cy Young Award winner be fixed? Has there been a worse season following a Cy Young season?

It's a question that I have been pondering most of the young season and something I started looking at the past few weeks. My first thought was there could be something to do with a small change in mechanics. Not necessarily intentional change, but something that crept in there that he hadn't fixed yet. Several videos and angles later, I hadn't noticed much and gave up. Plus, his release point is nearly identical to late last season and similar to most of the last year. Even if you compare the release point clusters on start by start basis, they are similar in size. So, it's not like his mechanics are all of a sudden all over the place. No, I think the issue could be much more foundational and different than your standard set of problems.

As many have already seen, the issue is primarily that there are a few more pitches left up in the zone. For a pitcher with top of the line stuff, that's not that big of a problem. But, for a pitcher who lives by painting the edges and inducing ground balls with low in the zone pitches, that's a big problem. An upper-80's fastball, even with movement, can still get crushed in the middle third much more easily than a mid-90's fastball.

Here is his location plot from 2015:

BrooksBaseball.net

Very light in the top third of the zone and warm in the lower third. Most of the pitches were out of the zone.

Compare that to 2016:

BrooksBaseball.net

The highest percentage of pitches in the zone is dead center. There were five locations with higher percentages than the 5 spot in 2015. The 2 and 3 zones are much higher in 2016. He's mostly worse in where his pitches are ending up in the zone in 2016. This basically supports the notion of diminished command this season.

I've merely identified the problem and supported the widely-accepted hypothesis. We have to identify the root cause of this and find out how to fix it. Since it's not mechanical, we're left with training regimen, which has been identified to be lighter this year to account for the higher workload. The other is a mental thing.

Command is mostly a "feel" thing in that you have to have a good feel for your release point and of the ball to manipulate it into going exactly where you want it to. Less off-day throwing can theoretically make it longer to get a feel for that. Except Keuchel was exactly what we expected in Spring Training. He didn't have the same issue. I know. Small sample and it was Spring Training. But, those grooved pitches can still get crushed in ST and he only allowed two walks, so he had better control. So, while it's plausible, I'm not buying that a lighter throwing program is at fault. I'm also not buying the "more pressure" theme either. A regular season game is not as much pressure as a wild card game in Yankee Stadium. He was lights out then and has the mental fortitude to handle this.

So, allow me to postulate a completely different approach. Something that I hadn't really considered at all until Sunday when I got an email from a reader of this site, Dr. Rick. He sent me this video with the idea that it could have implications to Keuchel.

Note: There is some medical jargon involved. Only the part about Thoracic Outlet Syndrome is necessary for this discussion. It starts at 6:45 and ends at 13:30.

A little background about Mike Reinold to show his expertise first. He has worked with the Red Sox as the head athletic trainer and Physical Therapist and currently consults with the Cubs. He's worked with the likes of Dr. James Andrews and Kevin Wilk (one of the leaders in Tommy John Rehabilitation), and American Sports Medicine Institute (the group that has brought the most research involving pitching mechanics to the world). He knows his stuff.

Thoracic Outlet Syndrome (TOS) is a compression of the nerves and/or subclavian artery (or on rare occasions, vein) that go down the arm. Compression of nerves affect the signals the nerves carry, whether that is to the muscles from the brain or from the arm to the brain. This can cause numbness, diminished sensation, swelling (very rare), cold sensations, color changes, tingling, and weakness in the arm/hand.The key for this discussion is going to be weakness and diminished sensation.

There are multiple ways for this to happen. The first is that all these nerves in the arms pass between the anterior and middle scalenes.

When those two muscles are tight (due to being short/inflexible), have increased tone (or over-active), or are too large (hypertrophied) they can diminish the space in which the nerves move and as a result get compressed. The second is that the first rib becomes hypo mobile, or stuck in an elevated position, and pushes upward against these nerves. The third is that the clavicle/collarbone is pulled down too much and compresses the space between it and the rib cages, which is where these nerves run. The last is that the pec minor is tight, has increased tone, or is too large and compresses the nerves itself.

I have been saying clinically that thoracic outlet is much more prevalent than given credit for a few years. I have treated so many patients with diminished sensations, numbness, or tingling and the doctors say it's because of a bulging disk or stenosis. The research out there shows I'm not actually going to make much change on the bulge of a disk or size of a foramen for the nerves to come out, but I can change their symptoms. So, that change has to come elsewhere. This is where it is. Yes, sometimes it does come from the cervical spine, but I have found more come from TOS. And it's not always major or not there. There is a spectrum. What some will jump to is "pinched nerves take a long time to heal." And a medically significant pinched nerve absolutely can. But, that's the major end of the spectrum. TOS can absolutely be major and can even require surgery to remove the first rib. The opposite end is an asymptomatic diminished sensation. And by that I mean, the sensation is there for normal everyday activities and you wouldn't notice that it's diminished, but it's enough to affect such a finely tuned release point.

How does this relate to pitching?

There's been a lot more talk about TOS in baseball players recently, but the majority of what I've heard is about blood clots in the pitching arm. But, this is very plausible.

Consider the pitching delivery and how it's rotational and full of momentum. Because of how the glove side has to decelerate and the body comes around, the body naturally wants to fall towards the glove side, and that includes the neck. So, the scalenes on the throwing side work eccentrically during the delivery. Eccentric contractions have been shown to increase muscle cross-sectional area (size). The other part is that because the majority of today's population have a forward head posture and the scalenes are usually tight/have increased tone in that posture.

The stage for nerve compression is definitely there for TOS from the stand point of scalenes. Now, the scalenes also attach to the first rib. So, if they are tight or too strong, they can elevate the first rib. This is actually how the scalenes are accessory muscles for breathing since they can help to assist in expanding the rib cage to pull air in. Consistent elevation of the first rib is one of the ways that TOS happens. Also very plausible.

Pitchers commonly have shoulders that are stuck in the downward rotation. Think of someone with very sloped shoulders and that downward rotated shoulder posture. That pulls that collarbone down to the first rib and compresses the nerves in that way.

The last is the pec minor. Think of the big bulky weight lifters that only do bench press and how their shoulders round forward. This posture and the downward rotated posture are both characteristic of tight pec minor. The issue here is that the pec minor is also usually fairly flexible in pitchers since they have to allow the shoulder blade to tilt back a lot in order to reach the extreme external rotation of the shoulder that pitchers reach. So, while it may not be tight relative to you and me, it could be relative to what a pitcher needs.

Mike Reinold did a great job explaining parts of it in the video above, so if you skipped it, I highly recommend watching it. The only thing I want to really add to this is that I agree you won't atrophy the scalenes. But, the tone issue to me is more modifiable. Improving posture and working on ways to improve eccentric control can allow for the scalenes to relax and have a more natural tone. Theoretically, that could have a good impact. Reinold mentions manual techniques as things they are trying and that's what I've incorporated into my treatment plan. First rib mobilizations are also things I've personally done. In fact, I've found that manual stretching techniques have been the most beneficial. That combined with working on cervical stability with upper extremity movements has been the most beneficial for my patients. Assessment of the thoracic spine (especially C-T junction) and shoulder posture is also needed. With pitchers, in particular, a better-decelerated glove side improve torque at the neck and reduces the eccentric force needed from the scalenes.

Without being able to assess Dallas Keuchel individually, I cannot definitely say that is what is going on. But, if the mechanics look intact and his velocity has crept up to near normal levels, there has to be something else. The command issues fits in this alternative paradigm of thinking. It's definitely worth looking into being as we're talking about less than an hour of treatment a day. The worse the TOS, usually the longer the duration of the episode. So, being that this is a potential underlying problem, the episode shouldn't need a long time to absolve.