By Dr. John R. Mishock, PT, DPT, DC
Overuse injuries in the shoulder and elbow are the most common problems in baseball players. Injuries of the shoulder account for 14-21%, whereas the elbow account for 16%-22% of all baseball-related injuries. (Agresta et al. Orthop. J Sports Med, 2019, Posner et al. Am J Sorts Med, 2011). Despite pitch count rules and guidelines, youth elbow and shoulder injuries are rising. The fastest-growing Tommy John Surgery segment (elbow ulnar collateral ligament tear) is in 15-19 year-olds at 57%, followed by 20 to 24-year-olds at 22% (American Journal of Sports Medicine, 2016).
Repetitive elbow valgus forces (late cocking phase elbow stress) cause microtrauma to the ulnar collateral ligament (Tommy John Ligament). These forces, over time, cause weakening of the ligament, predisposing it to acute or chronic rupture.
A recent systematic review suggests increased shoulder and elbow mechanical load (measured by pitch count or training hours), poor throwing mechanics, and higher pitching velocity lends to shoulder and elbow injuries. Also, physical factors such as decreased shoulder range of motion (especially flexion, internal rotation, and horizontal adduction), weakness (hips, core, shoulder, and scapular muscles), and limited hip joint mobility (especially internal rotation) are the potential risk factors for both shoulder and elbow injuries. (Reiman et al. J Shoulder Elbow Surg 2019, Mine et al. M Muscskl Sport Physio, 2021) Despite the widespread belief that throwing a curveball leads to elbow or shoulder injuries, the scientific evidence refutes this myth. (Escamilla et al. Am J Sports Med 2017, Norton et al. AM J Sports Med 2019)
As many as 10% to 25% of active MLB pitchers report a history of Tommy John Surgery, and there has been an estimated 10-fold increase in cases among professional players since 2000. (Conte et al. Am J Sports Med 2015) Similar trends have been seen in the general baseball population, with a recent study indicating a 193% increase in the incidence of Tommy John Surgery from 2002 to 2018.
Some parents and coaches believe that having Tommy John Surgery should be an elective procedure to enhance baseball pitching. Up to 25% of media members who cover professional baseball and 51% of active high school players believe that Tommy John Surgery can improve pitching performance. However, this common belief is not substantiated in the scientific literature. (Ahmad et al. Phys Sportsmed. 2012)
At the Major League level, return-to-play can be expected in 63% to 87% following Tommy John Surgery (Erickson et al. Am J Sports Med; Keller et al. J Shoulder Elbow Surg. 2014). When the Major League pitcher returns to play, there is a significant decrease in pitching accuracy (9% reduction) at 1 and 3 years post-surgery. Fastball velocity can be reduced by 3-5 mph. (Jiang JJ Am J Sports Med. 2014) Studies also show a significant postoperative decline in ERA, walks plus hits per inning pitched, and batting average against compared with the year before surgery. (Makhni Am J Sports Med. 2014). Many declines in pitching metrics spell the end of the “dream” with forced early retirement.
How can we prevent arm injuries?
Preventing or minimizing arm injuries is multifactorial, with critical components resting on the intensity,
frequency, and duration of pitching and throwing.
- Recognize signs of pitching fatigue. Fatigue is the most significant predictor of arm injury while throwing. There is an astounding 36 times increase in arm injury when a pitcher throws while the arm and body are fatigued. (Pitch Smart, MLB 2015). Recognizing the early signs of fatigue and removing them from throwing is critical.
- Use pitch counts as a guide. Pitch counts are the maximum number of throws, not a mandated number to reach for a given period. Each pitcher is very different in; physical maturity, previous injury, pitching mechanics, and throwing history. With that, coaches and trainers need to individualize the pitch counts to be specific to the athlete throwing.
- Rest from competitive throwing for 3-4 months. If a pitcher throws greater than eight months per year, there is five times increase in an arm injury. If the pitcher throws on consecutive days, they have more than 2.5 times greater risk of experiencing arm pain. (Pitch Smart, MLB 2015; American Journal of Sports Medicine, 2016).
- Reduce the intensity of the throws, aka throw the fast ball less. MLB pitchers who threw more than 48% of fastballs during practice and games had a significantly increased risk of an elbow injury, which required surgery (Journal of Shoulder and Elbow Surgery, 2016). Another study showed that the most significant risk of needing elbow surgery in MLB pitchers was the greatest fastball velocity (American Journal of Sports Medicine, 44, 2016). The change-up is the safest pitch, producing 5-10% less stress than the fastball. The bottom line should always be to learn to throw strikes first, with less concentration on velocity.
- Develop mechanically sound pitching mechanics. Proper pitching mechanics can reduce arm injury by using the larger muscles of the lower half (legs) and core (abdominals and hips) when throwing. Remember that only 15% of the arm creates throwing velocity when sound pitch mechanics are utilized.
- Begin a baseball specific sport performance exercise training program. The program should emphasize age-appropriate exercises to build general athleticism can help to reduce injury. The program should emphasize balance, mobility/flexibility, and strength/motor control exercises of the lower extremity, core, and shoulders. Playing multiple sports up to high school can be a great way to create diversity in exercise and movement.
- Institute a progressive arm tolerance throwing program. The goal would be to build throwing endurance and tolerance to pitching over time. This throwing program would be used in complement to pitching mechanics training, with a gradual progression of throwing (following 2-3 months off of throwing in the offseason). The pitcher would increase throwing volume by 10% per week in the late winter leading into the pre-season. The key to the progression is to balance the acute/chronic workload ratio leading to physiological gains in strength, endurance, and motor control.
With the above arm injury prevention techniques, we can reduce arm injuries in our young athletes. Keep in mind that the MLB draft pick will need durability as much as ability.
Dr. Mishock is one of only a few clinicians with doctorate level degrees in both physical therapy and chiropractic in the state of Pennsylvania.
He has also authored two books; “Fundamental Training Principles: Essential Knowledge for Building the Elite Athlete”, “The Rubber Arm; Using Science to Increase Pitch Control, Improve Velocity, and Prevent Elbow and Shoulder Injury” both can be bought on Amazon.
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