Jun 21, 2022
Protecting the Young Elbow, Part II
P.J. Gardner, MS, LAT, ATC, CSCS, PES

Elbow injuries in young baseball pitchers continue to rise and reduce participation. Second to the shoulder, the elbow is a vulnerable area and prone to injury in the young throwing arm. Unfortunately, many young pitchers experience elbow pain – and it should not be ignored. The elbow is susceptible to injury from the high valgus forces placed on it from pitching at all levels.

This is the second installment of ‘Protecting the Young Elbow,’ which appeared in the May/June 2022 issue of Training & Conditioning. 

2 Newer Risk Factors

elbowIn an interesting study of junior level baseball players (6-12y.o.) by Sakata, J. et. al. in 2016, some newly discovered risk factors were revealed for medial elbow injuries. One was the thoracic kyphosis angle as measured by an inclinometer summation of angles > or = to 30 degrees over the first, second, and twelfth spinous processes. This condition can alter scapular dynamics and increase the valgus forces on the UCL.

Another risk factor revealed in predicting an elbow injury was an elbow extension deficit > or = to 5 degrees. These two conditions could easily be evaluated in the PPE exam prior to each season. Although not found in the literature, it is this author’s belief that one of the risk factors can be extended to the adolescent (13-18 y.o.) population, as poor posture (thoracic kyphosis) is often seen in this age group also.

Another predictive factor for elbow injury was >100 throws per day where all positions practiced in a given day were included – not just pitches from the mound. An astonishing fact in this study alone is that the risk of medial elbow injuries in this age group (6-12 y.o.) may be reduced by simply improving posture (remember thoracic kyphosis) and keeping throws under 100 per day.

Throwing Mechanics

Throwing mechanics are another area of concern at all levels and are difficult to quantify — and what are proper pitching mechanics? They are discussed by many experts in baseball but are difficult to accurately identify. Video camera analysis is needed to properly evaluate pitching mechanics — and more importantly — a trained professional needs to do the evaluation. A “trained professional” is open for discussion. Most high school, college, and professional pitching coaches know how to evaluate pitching mechanics. Parents especially need to be careful in deciding who evaluates a young pitcher’s mechanics — as there are several “self-claimed” experts in the field.

A thorough evaluation of the movements involved in the throwing motion can reveal abnormal throwing mechanics possibly leading to injury. Corrective exercises can then be prescribed to correct any mechanical deficiencies. Corrective exercises could include standing external rotation, eccentric ball toss, scapular strengthening exercises, single leg balance with perturbations, and hip abductor strengthening.

Warm-up Pitches

In the junior level players, the number of warm-up pitches thrown — which most of us have not considered being a risk factor for injury in the past — was also examined suggesting, “there may be an upper limit to the optimal number of warm-up pitches” for this age group (6). To my knowledge, no exact number of age-specific warm-up pitches has been determined. It would make sense to include warm-up pitches in the total pitch count but, this is not done and could increase one’s pitch count by at least 15-30 pitches depending on the number of innings pitched. Even though these pitches are usually thrown at a lower velocity they still require energy expenditure and produce valgus forces on the elbow. The question remains: why aren’t warm-up pitches included in the total pitch count?

Showcases & Radar Guns

Showcases are another concern because of the radar gun being used to clock the speed of various pitches. The use of radar guns is necessary for scouts to clock exact velocities of the various pitches but, unfortunately, it also can cause pitchers of any age to overthrow and risk arm injury to impress scouts. The higher velocity a pitcher can throw, the less time a batter has to decide to swing – so, unfortunately, velocity is of great importance to pitchers at any age and is one of the metrics scouts examine closely. This is an ongoing concern for parents and coaches because the last incident anyone wants is for a shoulder or elbow injury to occur at a showcase. The ASMI position statement previously mentioned suggests not using radar guns. It was also suggested by the USA Baseball Medical and Safety Advisory committee “young baseball players not go to showcases.” However, the use of radar guns is prevalent at most showcases for adolescent baseball pitchers and is unlikely to change. 

Other Suggestions

elbowIt is also suggested that pitchers should not be catchers too – as this may result in too many throws in a game or practice. Remember, 100 throws in a given practice – regardless of positions played is the recommended maximum daily amount. In 2006, a recommended maximum competitive pitch count per year was 2500 for adolescent baseball pitchers. That could be 25 games where up to 100 pitches are thrown. In 2013 the ASMI suggested not pitching more than 100 innings per year. That is just over 15 – 7 inning games in a calendar year.  Another suggestion by the USA Baseball Medical Advisory and Safety Committee was “14 y.o. pitchers do not throw more than 75 pitches per game and fewer than 3000 pitches per year.”  So, the recommendations continue to be adjusted by various organizations for adolescent and junior baseball players. 

Another risk factor mentioned in the Olsen study was taller and heavier pitchers were more susceptible to injury – most likely because they could generate more force/pitch velocity. It seems to me that not every taller and heavier player can generate more velocity than shorter and lighter players, but most probably do. More progress and specific studies on junior and adolescent baseball pitchers’ risk of injury are needed to further protect the young arm.

Additional Concerns: NSAIDS/ICE

Often overlooked is that NSAIDS are routinely taken for soreness and pain by young baseball players – who oftentimes take more than the recommended dose. I often see these young athletes take 3-4 NSAIDS at a time and I quickly remind them of the dangers of taking more than directed. For OTC drugs, there is much wisdom in the words “take as directed”. The pain in the shoulder or elbow could be a warning that something is wrong. Evaluation by a Licensed Athletic Trainer (LAT) or other healthcare professional is in order.

In regards to icing, here’s a stunner: “Scientific research does not support the use of ice.” Icing is another common practice that is overdone for pain and recovery. Newer research indicates icing an injury can actually impede the healing process by blocking the release of IGF-1 for tissue repair. Articles like “Why ice doesn’t help an injury” by Aaron Hutchins and “RICE: The End of an Ice Age” from Stone Athletic Medicine going back as far as 2014 reiterate the same findings.  

I realize telling a baseball pitcher not to ice a sore arm is difficult but, always icing the affected area needs to be re-examined more closely and I would encourage all athletes to allow the natural inflammation process to occur when dealing with just muscle soreness. There is a physiological difference between muscle soreness and musculoskeletal injury. It is this author’s belief that icing an acute injury for 5-10 minutes for pain control is ok – although I realize that too can be controversial. We will continue to hear more about icing injuries in the future.


The medial elbow is a vulnerable area in young pitchers and any elbow pain should be addressed immediately. The high valgus forces of pitching put tremendous stress on the ulnar collateral ligament (UCL). It is the late acceleration phase of pitching where the most torque along with the greatest likelihood of injury occurs.

» ALSO SEE: Protecting the Young Elbow Part I

Some of the risk factors identified for medial elbow injury include: overuse, fatigue, pitching more than eight months per year, exceeding age-specific pitch counts, and throwing greater than 85 MPH. More interestingly, the kyphotic angle and elbow extension deficit were two newer risk factors found to lead to elbow injuries in young baseball players. Other areas of concern that tend to be ongoing are throwing more than 100 throws in practice/games, showcases, and using proper throwing mechanics.

Young pitchers that are taller and heavier tend to throw harder which could make them more susceptible to an elbow injury. Warm-up pitches may be a risk factor to consider and there may be an optimal number not yet identified. In addition, the use of radar guns is not suggested by some organizations but continues to be used by scouts. It is also advised that pitchers not be catchers also because of the risk of throwing more than 100 throws in a practice or game.

These are some of the latest challenges involved in protecting the young elbow and if the medical and academic community can continue to identify risk factors, parents, coaches, athletes, and healthcare professionals can take greater responsibility for taking the correct actions to actually reduce the number of elbow injuries in our young baseball players and keep them healthier and more productive through their adolescent years and beyond. 

P.J. Gardner, LAT, ATC, CSCS, PES, CES is the Athletic Trainer at Liberty High School in Colorado Springs. He writes various sports training/injury prevention articles for different publications. He can be reached at: [email protected]   

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