There’s A Lot We Don’t Know About Baseball and Softball Injuries

By Dev Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • There are likely many factors involved in shoulder and elbow injuries for young throwers
  • The available data suggests that there are steps a young thrower can take now to minimize risk.
  • These steps include: play less than 8 months out of the year; play more than one sport; maintain shoulder motion as close to the non-throwing shoulder as possible; and improve lower extremity and core strength

I’m still thinking back on a recently published study of MRI abnormalities in young baseball players. I wrote about this in a blog post and noted that in this small study 100% of the players had an abnormal shoulder MRI scan if they were single sport athletes and played more than 8 months out of the year. Sure, a larger study will likely show a different percentage but it still should give us all reason to ask: why does this happen?  And why did 74% of young players report some arm pain during play in another study? Is this just the new normal, the physical price paid to play the sport? The data are compelling and a bit scary, but still it’s not easy to connect the dots and identify specific causes of problems. There’s a lot we still don’t know.

There is a lot of outstanding research taking place now, attempting to answer the question: “why”. We’ll likely find that there are several factors that can conspire together to create injury risk, loss of performance, and loss of sport enjoyment. I’d like to highlight a few excellent studies recently published in the journal Sports Health.

Here’s an excellent study that starts to define what the normal pitching motion should look like in a young pitcher. The authors defined ranges for the normal shoulder rotation and elbow load and found interestingly that loads are actually less for curveballs compared to fastballs, and yet current pitching recommendations suggest avoidance of curveballs until around age 14. The culprit may actually be abnormal lower extremity and trunk mechanics in the young pitcher. Possible solutions: lower extremity and core strength should be a conditioning focus for the young thrower.

In another study the authors did a retrospective analysis of previously published data and found that shoulder rotational deficits correlated with risk of shoulder and elbow injuries in early adulthood. These authors feel that with the onset of puberty and the accelerated growth in the young body, it seems that repetitive overhead activity leads to changes in bone shape. Once the young thrower is finished growing the continued repetitive stress in throwing is transmitted to the soft tissues. Possible solution: improve shoulder, elbow, and trunk range of motion with a program such as the Yokohama Baseball-9.Sideline Sports Doc Logo

These and other studies point to the fact that there are multiple factors involved in creating the recipe for upper extremity injury. There’s a lot we still don’t fully understand. But there are reasonable steps any young thrower can take right now to reduce injury risk and maximize sport performance and enjoyment. Play less than 8 months in a year and play more than one sport. Keep shoulder motion as close to the non-throwing shoulder as possible, and keep lower extremity and core strength up.

Overthrowing: Abnormal Shoulder MRIs In Young Baseball Players Without Shoulder Pain

By Dev Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • A recent medical study showed that more than 50% of throwing shoulders in young baseball players without shoulder pain had MRI abnormalities
  • These MRI issues have the potential to cause long term issues for the shoulder
  • Players who played more than 8 months out of the year and were baseball-only athletes had a 100% chance of an abnormal MRI, regardless of playing position

At least once a week I’ll see a young athlete in the clinic with shoulder pain and at theYouth Pitchers end of a careful discussion, physical exam, and further discussion with the parents I’ll hear “that’s great, now can he have his MRI this afternoon”. The desire for an MRI is normal and natural on the part of the parents, after all this is what the media tells us will happen in a professional athlete.

(And btw the truth of that interaction with a pro athlete is frequently very different than what’s reported). But this study, published about a month ago in the Orthopaedic Journal of Sports Medicine provides valuable insight. An alarmingly high number of non-painful throwing shoulders in young athletes will have MRI abnormalities compared to the athlete’s own non-throwing shoulder.

The shoulder is frequently injured in young baseball players. Sports medicine doctors will often treat these athletes for overuse injuries and structural problems. Many of these diagnoses have long-term implications, sometimes requiring surgery and putting young athletes at risk for future problems. You’d be far better off not having any of these conditions.

Author Andrew Pennock and colleagues from UC San Diego orthopaedic surgery performed the study. They performed MRI evaluations on 23 young male baseball players aged 10-12 with no reported shoulder issues, and did MRI scans on the throwing and non-throwing shoulder.

Here were some of their key findings from the MRI portion of the study:

  • 52% of the throwing shoulders had MRI abnormalities that were not present in the non-throwing shoulder
  • They identified 2 key risk factors: year round play (defined as 8 or more months of baseball play per year) and single sport specialization
  • If a player had 1 of the 2 risk factors there was a 71% chance of an abnormal MRI; and with 2 of 2 risk factors there was a 100% chance of an abnormal MRI
  • Player position did NOT correlate with an abnormal MRI, meaning that fielders could also have an abnormal MRI

There were also some interesting observations about player behavior and knowledge of rules and recommendations for shoulder safety. 83% of the players were aware of pitch count restrictions, innings restrictions, and PitchSmart recommendations, and yet it appears that the number of players who actually followed the recommendations was small. In this study, 43% played baseball more than 8 months per year, 22% were single-sport athletes, and 80% of pitchers threw curveballs, sliders, and sinkers.

There are some limitations to this study that require additional investigation. It’s a fairly small number of players, and we don’t actually know what happens down the line to the shoulders with abnormal MRI scans.Sideline Sports Doc Logo

If you’re parents or coaches of young baseball players please have a look at the guidelines and rules in place from Little League Baseball and PitchSmart, and then make a commitment to actually follow the rules. A healthy arm is much better for long-term health and near term performance.

Help For Elbow Injuries In Pitchers? A Prevention Program Offers Hope

By Dev Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Overuse injuries to the elbow are common in young baseball players, and prevention programs are needed to reduce injury risk
  • A recently published scientific study highlighted the potential benefit of a stretching program called the Yokohama Baseball-9, showing a significant reduction in elbow injuries for players who used the program compared to those who didn’t
  • The program has the potential to be a useful tool in reducing numbers of elbow injuries for young baseball players

I’m a big believer in prevention programs for sports injury risk reduction and this week we’ll discuss a program to reduce elbow injury risk in baseball.

I’ve written before about the usefulness of the 11+ warmup program for lower extremity risk reduction in soccer. That program is highly effective. Prevention programs are great in theory but actually proving the usefulness can be difficult. What are required are often lengthy scientific studies with large numbers of individuals. Those types of studies have been done with the 11+ but are lacking for elbow injury prevention programs in baseball. But a recently published study from Japan offers some hope.

The study authors devised the Yokohama Baseball-9 (YB9) program, which consists of 9 flexibility exercises focused on the wrist, elbow, shoulder, and hips.

There were 275 players age 8 to 11 divided into a non-YB9 group and a YB9 group. Players were asked to complete the program at least once a week.

At 1-year, the YB9 exercise group had significantly lower rates of elbow injury and significantly better total range of motion at the shoulder. In a statistical analysis, increased shoulder total rotation, increased nondominant hip internal rotation and improved spine posture predicted lower rates of elbow injury.

This is a good study but there are some weaknesses. 28% of the original group was excluded due to prior shoulder or elbow pain and an additional 15% were lost to follow up. And it is a relatively small number of players who participated.

We need more studies like this so I hope it can be repeated by others, and with larger numbers of players. The fact that 28% of the young players in the original group of potential players were excluded because they already had pain in pretty alarming, and good evidence that we need some solutions to the problem of overuse injuries in baseball pitchers.Logo

Overall, the study is encouraging and provides an interesting new potential avenue for injury prevention.

The Runner’s High

By Dev Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of, Orthopedic Surgery, Stanford University

Key Points:

  • When your body comes under stress or experiences pain, neurochemicals called endorphins and endocannabinoids are produced in the brain. This happens in all age groups.
  • Endorphins and endocannabinoids are considered natural painkillers because they activate receptors in the brain that help minimize discomfort
  • These brain chemicals are naturally produced as a result of exercise and are likely responsible for the feeling called “a runner’s high”

Whether you’re a young athlete or an adult, many of you have experienced a post-workout high. People love the feeling so much that “endorphin junkie” has even become synonymous with someone who’s constantly chasing that exercise high.

When your body experiences physical or even emotional stress, neurochemicals called endorphins are produced in the brain. Endorphins, which are structurally similar to the drug morphine, are considered natural painkillers because they activate receptors in the brain that help minimize discomfort. They can also help bring about feelings of euphoria and general well being.

The idea that exercise creates a huge endorphin rush entered popular culture soon after endorphins were discovered around 40 years ago. The legendary Dr. Jim Fixx started America’s running revolution back in the 1970’s, and there was thinking that endorphins could play a big role in the psychological benefits of running and exercise. But no one really knew for sure.

The problem with jumping to the conclusion that endorphins cause your “exercise high” is that in large-scale studies, scientists measure endorphins present in the blood — not the brain. Then, they make the assumption that if endorphin levels rise in the blood, then it must be because of an increase of endorphins in the brain. It’s a logical assumption but the reality is a bit more complex.

In fact, a German study found that, while endorphin levels are higher after a run, the real brain chemicals responsible for the runner’s high are called “endocannabinoids”. These substances are similar to the key chemical in marijuana. At least that’s true in running mice, who kindly volunteered for the study…

So if you aren’t an endorphin junkie, then what are you? You’re probably an endocannabinoid junkie! That just doesn’t have the same nice ring to it though, does it?

Regardless of what the actual reason is for the good feelings after exercise, the point is that you need to just get out and do something. It’s good for what ails you.

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US expect the world will eventually catch up with heading ban

Uefa said it would consider implementation which would apply to all under-10s

The US has already taken proactive action with a heading ban in place since 2015. Photograph: Getty Images

A top football executive believes the rest of the world will eventually catch up with the United States’ pioneering ban on heading in youth football.

The Professional Footballers’ Association has advocated the move, which would apply to all under-10s, and in January European football’s governing body Uefa said it would consider implementation if its own study provided sufficient evidence.

A major study into the long-term effects of heading and potential links to dementia and brain damage commissioned by the English Football Association and English PFA began two months ago but initial findings are not expected for at least three years.

However, the US has already taken proactive action with a ban in place since 2015.

Kevin Payne, the chief executive of US Club Soccer, national association member of the United States Soccer Federation principally involved in youth football, was involved in the discussions which led to restrictions being brought in.

“While there is not a lot of direct evidence or research which draws a straight-line correlation between heading a ball at young ages and potential issues later in life we think it is a logical assumption as younger children’s technique will not be as good and their brains are not as fully developed,” he said.

“Until such time as that research has been completed and there are conclusions to be drawn we thought it was much safer to err on the side of caution.

“When you are talking about someone’s brain it is a big deal and we need to be almost overly-protective in this area.

“Part of the issue is that no one really knows what are the consequences of heading a ball at this young age.

“Until we do know the answer the only responsible course of action is to do everything possible to minimize the chance of it creating problems.

A top football executive believes the rest of the world will eventually catch up with the United States’ pioneering ban on heading in youth football.

The Professional Footballers’ Association has advocated the move, which would apply to all under-10s, and in January European football’s governing body Uefa said it would consider implementation if its own study provided sufficient evidence.

A major study into the long-term effects of heading and potential links to dementia and brain damage commissioned by the English Football Association and English PFA began two months ago but initial findings are not expected for at least three years.

However, the US has already taken proactive action with a ban in place since 2015.

Kevin Payne, the chief executive of US Club Soccer, national association member of the United States Soccer Federation principally involved in youth football, was involved in the discussions which led to restrictions being brought in.

“While there is not a lot of direct evidence or research which draws a straight-line correlation between heading a ball at young ages and potential issues later in life we think it is a logical assumption as younger children’s technique will not be as good and their brains are not as fully developed,” he said.

“Until such time as that research has been completed and there are conclusions to be drawn we thought it was much safer to err on the side of caution.

“When you are talking about someone’s brain it is a big deal and we need to be almost overly-protective in this area.

“Part of the issue is that no one really knows what are the consequences of heading a ball at this young age.

“Until we do know the answer the only responsible course of action is to do everything possible to minimise the chance of it creating problems.

“There were some individuals who were not happy about it and I am sure there are still, the old guard who think it is silly not to allow heading.

“But we think we are ahead of the curve on this. We think it is very possible that other countries will end up having a little bit of the same thing.”

The regulations have a huge support structure behind them which helps coaches and parents diagnose and monitor injuries with any head trauma flagged up with a warning to seek medical attention.

Dev Mishra, an orthopaedic surgeon at Stanford University, founded Sideline Sports Doc which offers an online course to help injury recognition which has amassed 50,000 coaches and staff members in just over 18 months.

“If we could find a way for these coaches to have some of this basic recognition maybe we could reduce the severity of injuries, especially concussion,” said Mishra.

“How do you figure out this kid has had a concussion and how do you remove them from play so they don’t have another?

“It is a very simple four-step algorithm which attempts to mimic for a coach what we as trained physicians do on the field of play.”

Online tool Player’s Health tracks athletes’ injuries and has 150 organisations from universities and high schools to clubs signed up for a wide range of sports.

“When your athlete is displaying more than one head injury in six months there is going to be a notification that the parent/guardian should be mindful and we can inform them of specialist facilities near them,” said Tyrre Burks, founder and chief executive.

“The whole system is around alerting everyone. The parent is notified and their kid is not allowed to come back and play until they have that medical clearance uploaded into the system.”

The Irish Times 3/20/2018