Are We Missing the Boat on the Yips?

It’s never a good sign when your doctor is excited about your diagnosis. That typically means that you’ve got some rare, unusual illness that the physician only learned about in medical school. Or that your physician is just a nerdy baseball lover and you have the yips.

As a family physician, when I met Coach X for his annual physical, he brought up the issue almost as a passing, insignificant concern. But as soon as he said the word “yips,” my heart was a-flutter. Like many fans, I’ve long been obsessed with the issue, ever since I had Mackey Sasser and Steve Sax baseball cards as a kid and learned about their throwing troubles. As a physician, it represented the power that mind plays over body, the power of recognized or subconscious emotion taking over your lifelong physical prowess, a loss of control and hope over a talent you’ve had your whole life.

We don’t seem to hear about the yips much, except for the few very apparent cases of players such as Steve Blass and Chuck Knoblauch. Dr. Steve E. Jordan, an orthopedist and colleague of Dr. James Andrews at the Andrews Institute for Orthopedics and Sports Medicine, has said, “It is not unusual for players to talk privately among themselves as it is often taboo to talk openly about the problem,” a sentiment seconded by many of the individuals whose careers this has affected. This is why I was surprised when Coach X actually brought it up in our visit, though also probably explains why he seemed to play it down.

The problem began years earlier and had been slowly worsening for Coach X. When he told me that he had tried physical therapy, psychotherapy from multiple sports psychologists, physical therapy, acupuncture, and hypnotism, I knew there was likely very little I could offer him. Even though he tried to seem coy about the issue, he also said that without a fix, he would need to find another profession that did not involve coaching Division I college baseball.

We decided to approach this from a different angle. I referred him to a neurologist, who like me also had no clue, and thus sent him to yet another neurologist who specialized in movement disorders (welcome to American health care). I feared he would get bounced around like this between multiple physicians, but as this threatened his livelihood, I wanted to do everything I could to help him.

He was diagnosed with a focal dystonia, a condition where certain muscles that have been used in repeated motions for years lose their ability to perform the task. This is common in the hands of musicians, but also seen often in athletes of other sports, such as tennis and golf. Often times the specific muscle or opposing muscle will contract or relax at the wrong time or in the wrong order, thus disrupting the proper flow of motion. It can lead to lifelong debilitation, or with proper medication and physical therapy, the function can return to normal. But because it does not originate from the mind, it does not respond to traditional psychological treatments.

He was started on trihexyphenidyl, a medication typically used to treat the tremors of Parkinson’s disease, which helped some but didn’t resolve his symptoms. Even though we had a few other things we could try, he was tired of the constant trial and error, and decided that it was time to move on and find another career.

The thing that stood out to me throughout this whole process, and makes it somewhat unique from the typical presentation, was that Coach X’s arm also didn’t function normally in everyday situations that had nothing to do with baseball. He had a hard time shaking hands sometimes. He was unable to water a house plant that hung above his head with his right arm. This seemed to go beyond mere psychology.

Even though dystonia is a known cause or contributor in some people, this is not what we typically think of as the yips.

In the video below, Coach X shows us two throws. The first shows a hitch in his shoulder while throwing, whereas in the second he is then unable to perform a throw at all. The dystonic reaction is present with all of his throws, though tends to worsen the longer he does it. His frustration also continues to grow as he throws more, which raises the question of how anxiety/stress could worsen the dystonia, or vice-versa. This was not only evident in overhand throws, but also in rolling ground balls for infield practice.

 
Because dystonia is presumed to be a relatively rare case with a neuromuscular origin of the yips, the case study on Coach X became the very first scientific article on the yips in baseball published in medical literature. With this in mind, it’s not surprising that players with the yips rarely are evaluated by an M.D.

“When discussing the [possible diagnoses], I do not include focal dystonia as I associate this with writers and musicians or perhaps golfers, and typically involving the hands and wrists, but not baseball players,” says Dr. Jordan.

“For baseball players with problems throwing, performance anxiety is at the top of [my list]. Very rarely mechanical problems or injury related problems are the cause. Most experts in sports psychology consider it a mental problem related to stress, anxiety or ‘misplaced focus’.”

Rick Ankiel, the pitcher who was forced to move to the outfield after developing an incurable case of the pitching yips, never considered the possibility of a neuromuscular cause like dystonia.

“I’ve heard it mentioned, but I never spent much time talking about it because I dealt with Harvey Dorfman, who was a sports psychologist, and we just never went there. We always just worked on the mental side of it.”

In his recently published memoir, The Phenomenon: Pressure, the Yips, and the Pitch that Changed My Life, Ankiel talks a lot about how the short throws were the difficult ones. But why could he throw just fine from the outfield but not when pitching?

“Why can I throw it 300 feet and not 60? I don’t know. It’s such a feel thing. You’re slowing your arm down, and now it’s that short throw. Maybe you’re not accelerating through the release point. There are definitely plenty of people who don’t like those short throws.”

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A dystonic cause of the yips in other sports is not a new concept. A few studies from the ’80s and ’90s show that a significant percentage of yips found in golfers (typically when putting) was not due to performance anxiety, but was neuromuscular in origin. Sometimes changing the grip on the club or adjusting the weight of the putter head solves the problem. Sometimes medication, such as the trihexiphenidyl and others, can help calm the unwanted tremor or twitch to help the golfer regain control.

But as Dr. Jordan said, the yips are nearly always considered to be mental. Golfer Tommy Armour coined the term “yips,” describing it as a “brain spasm” that disrupts your game. It typically starts unconsciously, often secondary to anxiety or stress. To compensate, you start to over-analyze things. Especially as a pitcher, with all eyes in the ballpark and TV on you, with time between each pitch to think (or overthink) about the next one, you can kind of drive yourself crazy. You are often embarrassed, or at least upset that you are losing your competitive edge. It becomes as if you are trying to consciously control a reflex—it just can’t be done.

This is why the first line of treatment is nearly always psychological. Things such as taking some time off, completing the movement in a different setting or with different conditions to change the context, using cue words to trigger an “auto-pilot” response, even evaluating for a prior life trauma, can help but often don’t make a significant impact. Some psychologists try immersion therapy, where the inciting event is replicated as much as possible and the athlete learns to accept and deal with the emotions of the situation. Sometimes drawing a lot of attention to it through treatment doesn’t change things, or may even make it worse. Many players have tried to deal with their loss of athletic ability through alcohol and drugs. Ankiel pitched drunk to calm “The Thing.” Most athletes will refuse to talk about it at all, especially to the media.

Dr. Jordan has found this to sometimes be problematic as it tends to breed unusual home remedies.

“In these situations, odd remedies or pharmaceutical options such as Adderall are suggested [by the player]. I refer these players to the sports psychologists.”

The “odd remedies” Dr. Jordan refers to often come from all sides. Family, friends and fans will often give their unsolicited opinion, often making the psychological isolation and mental prison of the yips even worse. Constant tinkering with various aspects of your body and life can be a real distraction.

“I had tons [of unsolicited advice], all kind of letters, you know, crazy stuff, like wear panties, do this, don’t eat sugar. You can’t listen to 10 million people trying to tell you what to do,” said Ankiel. “I trusted Harvey Dorfman, I let my trust lie in him, and he taught me how to cope, so that’s where I left it.”

One anonymous professional baseball player felt as if he had “a scarlet Y” placed on his resume, with teams then reluctant to give him another chance. Even if that wasn’t the reason he didn’t get his desired chances to play, the very fact that he believed it was from his prior yips could theoretically bring back any psychological extent of the problem.

All of this makes Ankiel’s willingness to talk about it all the more remarkable, though the silence of others means the complete story of the cause and treatment for the yips continues to elude us.

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I am not an expert on throwing mechanics or the field of kinesiology, but I do know that the mechanics of throwing from the outfield are different from pitching, or throwing within the infield. Is the difference significant enough to account for dystonia that would affect those short throws but not the longer distance throws, such as from the outfield? It hasn’t been specifically studied that I can find, but it’s certainly possible.

Shorter range throws, such as from second to first base, require more specific use of the hand, fingers and wrist for accuracy, the very same locations that Dr. Jordan says he thinks of in professional musicians or even writers who experience dystonia. While grips and wrist motion are obviously still important when throwing from the outfield, the increased use of shoulder and back muscles, along with the positioning of the legs for the proper kinetic chain to make the long throw, could theoretically lead to dystonia that is apparent with certain throws and not others. When Joel Stave developed the yips as a quarterback at the University of Wisconsin in 2014, he says, 30- and 40-yard passes weren’t a problem, but it was the short-range ones that became very difficult. Some baseball players like Ankiel — notably Knoblauch — have also made the transition from a yips-laden infield throw to a satisfactory throw from the outfield.

Could dystonia account for Knoblauch’s move to the outfield? Steve Blass’ inability to pitch? Sasser’s difficulty in throwing from home plate? Sax’s throws from second to first? I have no idea. Many baseball players who suffer from the yips do have a psychological cause, but how many are we missing who may have a neuromuscular condition? When Jon Lester throws wildly to first base, is it that he is anxious about it or that the mechanics and muscles used are different enough from his pitching motion that dystonia is not apparent in his pitching? Or maybe it is some mild dystonia that has led to some anxiety that has therefore worsened his throws? Or vice-versa? It’s tough to say.

The ultimate causes of the yips are not well understood — we just don’t have enough information. The one thing that all of the “experts” on the yips agree upon is that there is no expert on the yips. But as with Coach X, is it possible that we are misdiagnosing many players who may very well have a neuromuscular disease leading to their early exit from baseball? Maybe. If we properly diagnose and treat the problem, we may end up saving some careers.

References & Resources

• Kyle Bradford Jones, MD Juliann Allred, MD David Shprecher, DO, MSci, The Journal of Family Practice, “Muscle spasms, twitches in arm upon throwing • Dx?”
• Albert Chen, Sports Illustrated, “Yippee Ki-yazy: How Wisconsin quarterback Joel Stave got over his case of the yips”
• Rick Ankiel & Tim Brown, The Phenomenon: Pressure, the Yips, and the Pitch that Changed My Life