Watch the Ball … But Why?

Reflexes, Injuries and Musculoskeletal Medicine

Dr A Breck McKay, Bayside Medilink, Victoria Point, Queensland (mckayabATbigpond.net.au)

M
usculoskeletal physicians inevitably come swing, swipe, kick and miss more times than not. Some
across many sport-related injuries and fre- learn very quickly and show great skill early on, others get
quently hear the sporting catch phrase “watch to adulthood and just never really get it together.
the ball!” How many of them actually know why this is What is the mechanism here? The sportsperson must
important and how it can relate to the many injuries they firstly watch the ball and from that collect the information
see? required to swing the racquet, bat or stick. Then by the
From birth onwards we learn every complex action we complex calculations of the brain from the visual inputs,
do by very complex amalgamations of classical Pavlovian every muscle must be coordinated and move in the correct
conditioned reflexes.1 We first have to learn to roll over, to way and at the correct time to produce contact with the ball
sit up, to crawl and to stand, then to walk and run, and so and so make the ball do what you want! See Figure 1.
it goes on. Each stage can be broken down into very
simple single steps which are practised again and again,
until the conscious action is trained up and becomes an
unconscious reflex and automatic action.
Watch any baby trying to grasp something and you can
easily see some of these simple steps that are practised.
Watch a 6-12-month-old sitting in a chair and you will see
multiple steps occurring at once, depending on which
attention is being dominant. The hands and fingers are
feeling the table top, the feet and legs are changing
positions and the head moves depending on the visual,
auditory or olfactory cues being stimulated. Now catch the
baby’s attention with your eyes, open your eyes wide in
response and watch the baby’s response with an overall
reduction in the movement of head, body, arms and legs.
The baby fixates on your eyes … a learned response from
birth. This behavior change can even be effected in older
children, who know they are misbehaving, and it is amaz- Figure 1. The eye’s mathematical processes to judge the ball’s
ing how merely eye widening can work. It is also surprising position.
how quickly the mother responds to the child or baby’s
change in mood and activity.
Young children also run into objects and people very The fastest sport in the world is ice-hockey, although it
easily, but as they get older, become very nimble with their is only just ahead of Olympic-grade table tennis. So what
body position in space. How many times have you seen sort of ball speeds or time intervals are involved?3
teenagers on skateboards, zooming down pathways avoid-
ing many people without ever touching or crashing? Table 1.
To understand the next concept, also learnt from very Sport Ball Speed (kph) Distance Covered
early childhood, walk directly at a person in a shopping (meters)
centre but stare fixedly over their head at an object in the Cricket 150 20.12
distance. Watch with your peripheral vision, and see how Tennis 150-190+ 36.58
they become aware of you moving towards collision with Table Tennis 110 1.52
them. They will automatically change their direction to Baseball 145 18.44
avoid any impact without any other form of communication Ice Hockey 168 very variable (OK not
or acknowledgement. Just as a word of warning… do not a ball … Puck it!)
try this with women with shopping trolleys or prams in front
of them… they command right of way and will run into or The human body is very skilled at doing this, with some
through you, rather than change course. Not so with men!2 movements done automatically and some following thought
So what has this to do with “watch the ball”? Simple! The and reason. The simple reaction time is 150-200 millisec-
above demonstrates how we learn to position our body in onds. The time for recognition is 300-350 milliseconds.
space and in reference to others and objects. All is learnt The choice plus reaction time is 400+ milliseconds. It
by many trials and errors from childhood onwards. Now takes sensory impulses only 20 milliseconds for the nerve
think about young children trying to kick or hit a ball. They impulse traveling at 50 meters per second to reach the

May 2008 25
Watch the Ball … But Why?
cerebral centers and even less to activate initially the
midbrain areas. The responding motor pathways take half
that time to activate the muscles, conducting impulses at
100 meters per second.4
So how does the sportsperson overcome the seemingly
impossible task that defies conscious recognition times?
It is time to go back to anatomy, neurology and physiol-
ogy and first principles to understand the processes
involved. The oldest parts of the brain are the medulla,
pons and mesencephalon, which house all the primitive
survival/function centers and basic reflexes. To these
areas are linked the olfactory, visual and auditory inputs5
which respond faster and in less than 200 milliseconds,
and long before any higher cerebral center interpretation
of those inputs.
This Orienting or Focusing Response is not new and
was described precisely by Pavlov in 1910! This is linked
to the whole body function6 of vestibular postural control
(Figure 2), resulting in the MOMM process. Every animal
or person Monitors the environment (internal and exter-
nal) then Orients (directs the vision, olfaction or auditory
receptors to the change) to any change, followed by
Memory check for past experience knowledge and then
Manage the changed situation by flight/fight or fear/freeze
or return to normal.
Figure 2. The complex whole body function process and
vestibulo-posture control.
So when playing any ball sport, the aim is to watch the
ball every time and to gradually develop very rapid condi-
tioned reflexes and to increase the learned automatic
reflex activation via the orienting response and the mid-
brain connections.
Sir Donald Bradman trained his reflexes by hitting a golf
ball against a corrugated iron tank. Every cricketer learns
and trains his reflexes to respond automatically through
the midbrain pathways.
The longer one practises the better one becomes, which
is just like learning to drive a car. Initially all the attention
26
is taken up listening to the instructions, watching the inside
and outside rear vision mirror, looking forward through the
windscreen, changing the gears, putting the clutch in and
out, using the accelerator and brake pedals to move the
car steadily forward, keeping an eye on the road – mas-
sive sensory input all at once – on the first occasion! Then
as each set of actions becomes more familiar, it is rel-
egated to automatic and subconscious until the brain has
many superimposed automatic patterns7 which no longer
need conscious thought. Some people do it easily, some
less so and some never learn to drive.
The same applies to ball sports as it does to any skilled
process, such as being a surgeon, musician, or artisan.
So a good sportsperson always watches the ball and
allows their trained reflex responses to operate, often
without any higher center action or interpretation.
Now let us look at the opposite end of, say, a cricket
pitch. The bowler is trying to exert the maximum changes
after the ball hits the pitch, leaving the batsman totally
unable to make any alteration for the sudden change in
less than 100 milliseconds. The fast bowler uses the
seam, the spin bowler the spin on the pitch and the
swing bowler movement in the air over the last half of
the ball’s travel. All try to make the change occur in the last
100 milliseconds, which is outside the batman’s ability to
respond or alter their shot.
So why is this all important to the good musculoskeletal
physician? To comprehend the effects of any injury fully,
one must be able to collect all past data (learnt by the
patient but often forgotten), forensically dissect the de-
tailed action occurring in any motor vehicle accident, fall
down stairs, falls off horses, off bikes, onto the tailbone,
etc. To do this, one must understand the normal anatomy,
physiology, neurology, and so understand how, what and
why an injury has occurred.
Is there a simple analogy here? Of course! The atlas of
human anatomy is just like the road map of many suburbs.
Ask any patient to tell you the names of the last six side
streets they pass on the way home. If they recently moved
in, they can. If they have been there for years they have
trouble. Why? It’s because they forget the details which
they pass every day. If they need to go to Melbourne or
Sydney or Brisbane by car, they need a road map (or GPS)
to find where they are and how to get to their destination!
Doctors learn their anatomy in the first few years at
medical school, just like a road map and then as they
become familiar, they forget the details, but good muscu-
loskeletal physicians use the atlas every day and with
every patient, thus reinforcing their knowledge and notic-
ing/learning new bits all the time. They learn to tease out
the mechanism of injury in any past event that the patient
remembers distinctly, and consider its effect on the whole
body,6 as well as specific parts of the body.
On the other hand specialists learn their anatomy and
physiology not once but twice and in massive detail to
pass their primary examinations. But as they progress
they become used to using a single motorway without any
Australasian Musculoskeletal Medicine
 Watch the Ball … But Why?

side streets in one part of the body, all too often forgetting
the other bits. All doctors must return to their anatomy,
etc., to ensure that they remember the details properly.
References
1. Pavlov IP. Lectures on Conditioned Reflexes. The Classics of
Psychiatry and Behavioural Sciences. Library Reprint Gryphon
Editions, 1991 from the original text 1928. Chapters VIII p. 103,
XI p. 131, XXVII p. 276 and XXVIII p. 282.

Why is this like “watch the 2. Kandel ER, Schwartz JH, Jessell TM. Perception of Motion
Depth and Form. Principles of Neural Science. 4th ed. McGraw
ball”? Hill, 2000. Chapter 238 pp. 548-71.

Simply because, to any good doctor, if you do not watch
the ball/anatomy, do not seek all the relevant past history,
you will never be able to react automatically when you are
faced with a new injury or difficult musculoskeletal prob-
lem.
To become good musculoskeletal physicians, we must
practise again and again and not get into bad habits of
thinking and recording things which we may not have
done. We all know from patients’ information that some
specialists may fail in history taking and may do very
cursory examinations, (or which may not have been done
at all), yet the printed records suggest otherwise.
So when addressing any injury in any patient:
1. Take a thorough pain history and examination
8 9
2. Go back to the basic injury process involved (it may be
for any injuries that are remembered).
3. Review for forensic deconstruction (step by step) of the
mechanisms of injury. Determine the biomechanical
processes and factors involved.
4. Consider and explain the simple anatomical factors
involved using an atlas of anatomy, not sketches which
only confuse and leave the patient uninformed.
3. Kosinski RJ. A Literature Review on Reaction Time.
Clemson University.
4. “The Pathophysiology of Pain”. AstraZeneca Pharmaceutical
Education Booklets. J Pain and Symptom Management 2000; 19
(15).
5. McKay AB. Tennis Elbow Everywhere. Australas Muscu-
loskeletal Med 2005; 10(2): 127-30.
6. McKay AB, Wall D. The Orienting Response and the Func-
tional Whole Human Body. Australas Musculoskeletal Med 2003;
8(2): 86-99.
7. de Bono E. The Past Organises the Present: The Jelly Model,
Short Term and Long Term Memory. The Mechanism of Mind.
Simon and Schuster, 1969. Pp. 93-97, 111-16.
8. Bogduk N, McGuirk B. History. Medical Management of Acute
and Chronic Low back pain. An evidence based approach.
Elsevier, 2002. Chapter 6 pp. 28-40.
9. Bogduk N, McGuirk B. Physical Examination. Medical Man-
agement of Acute and Chronic Low back pain. An evidence
based approach. Elsevier, 2002 Chapter 7 pp. 41-47.

5. Explain how nociception passes via the spinal cord to

the brain. 4

6. Re-examine the patient by actually physically touching

and pressing on the involved areas.9

7. Explain what, why and how you are going to treat the
patient.

8. Remember everything you do has been learnt, just as

any sportsperson learns, by classical Pavlovian condi-
tioned reflexes and the commitment of knowledge from
conscious to subconscious and thus reflex and auto-
matic for most of it. (Most of what you do is automatic
and if learnt incorrectly, it is easily in error!)

9. “Watch the ball” to be a good musculoskeletal physi-

cian, and now you know why!

May 2008 27