By Dr. John R. Mishock, PT, DPT, DC
In my clinic, a 12-year-old boy and his parents present for a sports medicine consultation regarding his elbow pain. Following a 105 pitch outing, he felt significant sharp elbow pain. He stated the pain started about an inning before, but he was encouraged by his coach and parent to finish the game. An MRI of the elbow revealed a tear of the Tommy John Ligament of the elbow (ulnar collateral ligament). Unfortunately, this young athlete must be shut down from throwing and his baseball pitching career is in jeopardy… at age 12. We will try physical therapy first, however, to get back to throwing he may need Tommy John Surgery. I see this type of patient all too often. It is sobering and frustrating for me knowing that the young baseball player’s career will be significantly disrupted with their baseball future in jeopardy. With all the scientific information available on arm injury prevention, we need to be better. We coaches and parents put tremendous pressure on the kids to “win at all cost”, often encouraging the young athlete to perform beyond their body’s physiological capabilities.
Despite pitch count rules and guidelines, the incidence of youth elbow and shoulder injuries is rising. The fastest-growing segment of elbow Tommy John Surgery is in 15-19 year-olds at 57%, followed by 20 to 24-year-olds at 22% (American Journal of Sports Medicine, 2016).
Repetitive valgus forces (late cocking phase of the throwing) causes microtrauma to the ulnar collateral ligament (Tommy John Ligament) over time weakening its integrity and predisposing it to acute or chronic rupture. With excessive pitching and throwing, this destruction of the ligament is happening at younger and younger ages.
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 population, with a recent study indicating a 193%increase in the incidence of Tommy John Surgery from 2002 to 2011.
Some parents and coaches believe that if the young player sustains an elbow injury they will simply elect to have Tommy John Surgery. Up to 25% of media members who cover professional baseball and up to 51% of active high school players believe that Tommy John Surgery can enhance 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 of the declines in pitching metrics spell the end of the “dream” with forced early retirement.
What can be done to prevent arm injuries?
Preventing or minimizing arm injuries are multifactorial, with key components resting in the intensity, frequency, and duration of pitching and throwing.
First, prevention starts with recognizing fatigue while pitching. Fatigue is the greatest 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 the pitcher from pitching immediately is critical.
Second, we must use pitch counts as a guide. Pitch counts are the maximum number of throws for a given period, not a mandated number to reach. Each pitcher is very different in; physical maturity, previous injury, pitching mechanics and throwing history. With that, an individualized approach to pitch counts should be utilized.
If a pitcher throws greater than 8 months per year there is a 5 times increase of 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).
Third, 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 greatest 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.
Forth, proper pitching mechanics can reduce arm injury by using the larger muscles of the lower half (legs) and core (abdominals and hips) when throwing. Keep in mind that only 15% of the arm is used to create velocity when sound pitch mechanics are utilized.
Fifth, a comprehensive strength and conditioning program that emphasizes age-appropriate exercises to build general athleticism can help to reduce injury. The program should emphasize balance, mobility/flexibility, 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.
Lastly, an arm tolerance throwing program to complement the pitching mechanics training. The goal would be to build throwing endurance and tolerance to pitching over time. This would entail a gradual progression of throwing (following 2-3 months off of throwing in the offseason) by less than 10% volume 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 he will need ability. More information can be found in my book, “The Rubber Arm” found on Amazon.
We can help!
If pain or limited function is keeping you from doing the activities you enjoy, call Mishock Physical Therapy for a Free Phone Consultation (610)327-2600.
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Locations: Gilbertsville, Skippack, Phoenixville, Steiner Medical, Boyertown, Pottstown, and Limerick, (inside the Spring Valley YMCA)
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”, and“ The Rubber Arm; Using Science to Increase Pitch Control, Improve Velocity, and Prevent Elbow and Shoulder Injury”. Both can be bought on Amazon.