Apr 14, 2020Protecting the adolescent arm
“Baseball knows little on how to protect arms.”
This statement was made by Jeff Passan in his book, “The Arm.” He later wrote: “The arm confounds even the smartest people and inspires radical ideas, such as the best pitching prospects in a generation sitting out the playoffs in 2012 because maybe it would keep his arm healthy.” This statement was in reference to Steven Strasburg, a major league rookie sensation and 2019 World Series MVP. Even at the sport’s highest level, arm health is an ongoing challenge. It’s the same story at the high school level.
The arm of the young adolescent is one of the most overused and abused commodities in sports — particularly in baseball. Many young baseball and volleyball players, not to mention swimmers, suffer from overuse in their respective sport. At every level, we hear about baseball pitchers throwing too many pitches over a certain period of time and having elbow surgery or shoulder surgery as a result. What can be done to prevent this or, at least, reduce the number of injuries? This has been debated by physicians, physical therapists, athletic trainers, coaches and supporting organizations for the past few years.
One reason it’s important to protect the arms of young baseball players is they are in various stages of growth and development. They should be shielded from overtraining, especially throughout their formative years. Secondly, there isn’t a wealth of research on adolescent arm injuries. Therefore, all the medical professionals need to re-examine and adjust the current guidelines to reduce arm injuries and prolong careers. If the number of elbow and shoulder injuries has increased during the past few years, clearly something is wrong.
What’s the problem?
In a word: overuse. Coaches, parents and those closely associated with the teams routinely allow young pitchers to throw too many pitches in games or over the course of a season. The current guidelines are not followed or enforced as they should be. In my experience, there’s little communication between coaches, fall leagues, high schools and summer leagues. Some athletes play year-round without taking the two- to three-month break that’s recommended by the American Sports Medicine Institute (ASMI). This is a key factor in overuse injuries.
Each coach follows pitchers during their season, but no one seems to keep up with the previous season’s numbers, year-round totals or innings pitched. This is another issue that must be addressed.
Athletes playing baseball year-round are at particular risk for elbow and shoulder injuries. The American Academy of Pediatrics also recommends that pitchers quit throwing for two to three months each year, and it discourages specializing in one position.
A limit on the number of innings pitched each year needs to be established. The ASMI suggests no more than 100 innings per year, but most of the high school pitchers I work with admit exceeding this number. We must update the current guidelines and strictly adhere to them, otherwise we’ll continue to see problems in adolescent baseball players.
The rotator cuff
The rotator cuff is a structure of particular vulnerability in physically immature athletes who are still developing. It consists of four muscles: the subscapularis, supraspinatus, infraspinatus and teres minor. These muscles hold the head of the humerus in the glenoid fossa, and if any one muscle becomes strained, it can cause an imbalance in the cuff and lead to injury.
The glenohumeral joint has greater mobility in its range of motion than stability, and it’s one of the most injured joints in the young overhead athlete.2 In one study, supraspinatus strength was shown to decrease during the season for high volume pitchers.4 For these reasons, rotator cuff strengthening exercises should be standard protocol for preseason and in-season conditioning to strengthen and prepare the cuff for the forces required of overhead throwing.
“For all overhead athletes I recommend a program with high volume work during the preseason,” said KC Bonnin, the strength and conditioning coach at Liberty High School in Colorado. “I’ll implement Y, T, Ws, along with internal and external rotation band work.” This type of resistance training program helps to insure adequate rotator cuff strength prior to the season.
Overuse injuries in pitchers are believed to be from the repetitive overhead throwing motion that results in traumatic stresses to the shoulder muscles.7,8 Pitching-related injuries requiring surgery in high school pitchers has increased, which is surprising given the amount of medical knowledge and data available.7 One possible reason is that the angular velocity at the shoulder joint exceeds 7,000 degrees per second during the act of pitching.2,3 This puts tremendous stress on the shoulder joint. The young pitcher’s shoulder must be flexible enough to allow the external rotation required (about 180 degrees) to throw a baseball and be stable enough to prevent subluxations of the joint.2
Other conditions include “Little Leaguer’s shoulder,” caused by repetitive stress to the shoulder’s growth plate, which is more susceptible during growth spurts.8 Open growth plates are the norm for adolescent athletes. This is often overlooked with coaches and parents.
Multidirectional instability (MDI) is another issue that’s caused by rotator cuff weakness. It results in instability of the glenohumeral joint in two or more directions.8
With this in mind, adolescents commonly present with increased shoulder laxity. This may predispose them to injury when combined with the stress of repetitive overhead throwing.8 It appears that the greatest point of vulnerability is in the arm-cocking and acceleration phases, where maximal external rotation occurs.8 These are challenging mechanical and physiological conditions that should be considered when reviewing pitching guidelines for this age group.
The ulnar collateral ligament (UCL)
The elbow is another area of concern — specifically, the UCL. It’s well known because of the rise in Tommy John surgeries.
The elbow consists of the humerus, radius and ulna, and the flexion and extension of the arm is by structural design.6 Various injuries occur to young elbows, especially the UCL, which is on the medial side of the joint. With the forces routinely put on the UCL, this is an area prone to inflammation, soreness and tissue damage. This condition is often referred to as “Little League elbow.” Unfortunately, I often hear coaches, parents and athletes dismiss it as “routine soreness,” and they only address it with ice.
The overuse of NSAIDs for pain and inflammation is an ongoing concern at the high school level. Icing and NSAIDs for a sore elbow or shoulder is acceptable in the short term, but they should be fully evaluated by a medical professional before the athlete resumes playing. That way, you can rule out structural damage.
A positive apprehension or empty can test for the shoulder, or a positive valgus test, may indicate structural damage to the ligaments that require further intervention from a medical doctor. This is often disregarded in the young athlete, with many playing through the pain. Oftentimes, a young athlete is allowed to continue playing through this condition. Required rest days need to be established and enforced for specific soreness in the shoulder or elbow.
It’s imperative a coach, parent or athletic trainer know what objective signs to look for when young pitchers experience fatigue. The nuances of fatigue can be very subtle to the untrained observer.
It might be a certain number of pitches or a slight change in mechanics. Dropping the elbow and taking more time between pitches can be a sign of fatigue.1 Good coaches can quickly recognize when pitchers alter their mechanics due to fatigue. Rarely will a pitcher at any level admit being tired. It’s hard to objectively measure fatigue, especially in young pitchers, so we must scrutinize exactly what’s happening when real fatigue is apparent.
» ALSO SEE: Strength training during the baseball season
Fatigue can be measured subjectively on an analog scale of one to 10. But because of the competitive environment, I would question the accuracy of the response during a game. I would not ask a pitcher, “Are you tired?” That’s unlikely to elicit an accurate response, because athletes want to stay in the game.
In high school baseball, it can be challenging for coaches to determine when it’s time to remove a pitcher if he’s below the required maximum pitch count.
“It’s in everyone’s best interest to isolate the point of fatigue and determine when it begins to affect production,” Corey Dawkins, ATC, said in the book “Baseball Prospectus.” This philosophy can be applied to younger athletes. This is the point where the pitcher should be removed from the game, regardless of any other condition.
The ASMI believes that playing year-round is causing more injuries. It identifies other factors that can lead to arm injuries, including: private lessons, showcases, throwing at home after practice, number of throws during practice at other positions, playing for multiple teams in a season, and use of a radar gun. The ASMI suggests the maximum number of pitches per game/week/ year with each age group, and it recommends days of rest for recovery between outings. It also includes age recommendations for learning different pitch types due to differences in physiological development.
The pitch limits vary from state to state. The ASMI is a great resource, but are its recommendations enough? We must consider what else needs to be done to reduce arm injuries.
Pitch count is an obvious marker coaches should pay attention to, but the question is whether it’s enforced.
Only additional research can help us better understand how many pitches are enough. But it may be more a question of enforcement of maximum pitch counts. Maybe coaches should increase the days of rest between outings. Private lessons should be limited, or at least monitored, so the number of pitches can be added to daily or weekly totals. The honor system for reporting may have to come into play.
Showcases are a concern because of the demand for maximum velocity, which can cause a pitcher to overthrow. The timing of the showcase — in-season or offseason — also can be an issue. Playing year-round should not be allowed, as a two- to three-month rest period should be implemented. This might be a challenge for schools, leagues and everyone involved.
Because pitching through fatigue can lead to injury, coaches need to recognize the subtle signs of fatigue and take action by removing their pitchers. There also has to be a base of physical fitness, because fatigue can vary between athletes. This is the critical point everyone needs to recognize.
Young arms are constantly overused and injured as a result, so stricter guidelines must be enforced. The rotator cuff and elbow are prone to injury for a variety of reasons, and these injuries are on the rise. Prevention strategies include proper physical conditioning, rotator cuff strength and conditioning programs, and recognizing fatigue early and taking appropriate action.
Additional training activities and required rest should be monitored and documented. Pitch counts for games, seasons and the year must be re-established and enforced, and we must discourage pitchers from working through the pain.
Hopefully, sports medicine organizations can revise their position statements to include new recommendations to decrease injuries in the overhead athlete. Together, we can help to improve the current guidelines for injury prevention and further careers. That should be the ultimate goal.