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

Key Points:

  • Young pitchers are at risk for arm injuries due to a number of factors, and pitching while fatigued is perhaps the biggest risk for injury
  • MLB’s Pitch Smart guidelines are designed to reduce injury risk while still allowing for the competitive development of the young player.
  • Parents, coaches, and league administrators would be wise to implement the Pitch Smart recommendations for their pitchers

As spring and summer baseball is ramping up, I’d like to remind our readers of a terrific Grant Lewisresource for the young pitcher- MLB’s Pitch Smart guidelines. I’ve written about pitch counts, the “100 inning rule”, and pitching injuries in several other blog posts but it is worth pointing out some of the reasons why we should revisit this topic. Pitch Smart is an effort by Major League Baseball to critically evaluate factors responsible for injury risk to young pitchers and then create guidelines to minimize that risk. Pitch Smart is partnered with many of the brightest minds in sports health for throwers and has produced a set of recommendations based on evidence and experience.

The result of their effort is a set of age appropriate recommendations designed to keep young pitchers as healthy as possible.

We’ve definitely made progress in recognizing and putting in place recommendations to reduce injury risk, but as the website points out we still have some work to do. For example, a survey of youth pitchers published in 2014 showed that of the pitchers responding to the survey many were engaging in behaviors that risk the health of their arms:

  • 45% pitched in a league without pitch counts or limits
  • 5% pitched on consecutive days
  • 4% pitched on multiple teams with overlapping seasons
  • 2% pitched competitive baseball for more than 8 months per year

Those published statistics are a few years old and hopefully we’ve made some progress in this area thanks to the efforts of Pitch Smart and others.

Take a look at the age-specific guidelines. They are divided into 5 age groups. For example, in the 15-18 year group which would cover most of our high school aged athletes some of the key recommendations are:

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Players can begin using breaking pitches after developing consistent fastball and changeup

  • Do not exceed 100 combined innings pitched in any 12 month period
  • Take at least 4 months off from competitive pitching every year, including at least 2-3 continuous months off from all overhead throwing
  • Make sure to properly warm up before pitching
  • Set and follow pitch-count limits and required rest periods
  • Avoid playing for multiple teams at the same time
  • Avoid playing catcher while not pitching
  • Players should not pitch in multiple games on the same day
  • Make sure to follow guidelines across leagues, tournaments and showcases
  • Monitor for other signs of fatigue
  • A pitcher remaining in the game, but moving to a different position, can return as a pitcher anytime in the remainder of the game, but only once per game
  • No pitcher should appear in a game as a pitcher for three consecutive days, regardless of pitch counts

In my opinion, Pitch Smart’s recommendations are another example of much neededSideLineSportsDoc changes designed to keep young players playing longer and healthier. These are recommendations rather than rules, but if you are a league administrator I’d urge your league to have a close look at these recommendations and adopt them for your players.



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

Key Points:

  • Sport specialization by adolescent and early teenage athletes is associated with a relatively high injury risk
  • One study of Division 1 athletes showed that only about 17% of athletes were “highly specialized” when they were in 9th grade, with about 41% “highly specialized” by 12th
  • Only a small number of the athletes felt that they were pressured by their parents to specialize

Young athletes, and high school aged athletes in particular feel a lot of pressure to specialize in one sport. The thought is that by specialization you have a better chance of playing in college or in the pros compared to those who don’t specialize. But is this actually true?

Here’s an interesting study that took a look at this question. It’s titled “High School Sport Specialization Patterns of Current Division 1 Athletes” and published in the journal Sports Health. The authors used a survey of current athletes at the University of Wisconsin- Madison to assess how specialized these high level collegians were in high school.

Three hundred forty three athletes participated, representing 9 sports at the university. They found that sport specialization increased throughout high school, with about 17% “highly specialized” as 9thgraders and about 41% highly specialized by 12th grade.

Specialization was more common in individual sports (such as tennis, swimming, golf, etc.) and specialization was much less common for football athletes. The most common reason the athletes gave for specialization was simply because they enjoyed that sport the most, and the second most common reason was the opportunity to earn a college scholarship. Only 10% cited parental pressure as the reason for specialization.

Whenever possible, I encourage my young athletic patients to participate in multiple sports. By the time they get to me it means they’ve already had an injury and I’m trying to reduce their chance of having another one. There’s ample scientific evidence that sport specialization is a key factor in negative outcomes such as injuries, psychological burnout, and poor body movement patterns. And on the other end we have plenty of evidence that participating in several physical activities can have real benefits (except when you play multiple sports at the same time!).

Overall I saw a lot to be encouraged by this study, at least if you happen to be an SideLineSportsDocathlete in Wisconsin! It’s believed by many that early sport specialization is driven by parental pressure but in this survey only a small percentage of the athletes said they were highly influenced by their parents. Most of the time the focus towards a single sport was driven by the athlete’s enjoyment of the sport. Most athletes who are talented enough to be recruited to play a Division 1 sport will eventually specialize in their sport, but at least for this group of athletes it didn’t appear that early specialization was necessary to become a Division 1 athlete.


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

Key Points:

  • Wearable technology is very popular for monitoring steps, energy expenditure, and movement patterns.
  • The devices can generally be divided into step counters, accelerometers, GPS based devices, and physiologic measurement devices. Many systems combine several elements
  • The accelerometer and GPS based systems are likely to be useful for the young endurance sport athlete wishing to aim for peak performance
  • If you are using one of these devices for training it’s important to work with a coach experienced in interpreting the data for you

Wearable technology for adults is very popular, ranging from monitors like the FitBit, wearable technologyApple Watch, heart rate monitors, etc. In general I think there’s value for adults who are really interested in objective data to help them drive their fitness objectives and stay on track. But what about at the youth sports level? Are there technologies that could be useful to the young athlete?

This recently published article provides a nice overview of the available technologies when viewed from the sports medicine clinician’s perspective. I’ll review the categories of devices and provide some commentary on usefulness for the young athlete.

Step Counters

These devices are properly called “pedometers” and measure the number of steps taken by the individual. For adults the commonly used number is “10,000 steps a day for fitness”. There is some published evidence that pedometers help youngsters achieve a baseline level of fitness but we have no evidence that it will be of use to the young athlete. My conclusion for the young athlete: very limited value in using a step counter.


These days many people carry around in their pockets a device that has some accelerometer functions: it’s called your smartphone. Beyond that, fitness specific accelerometers are widely available. This is where devices such as the FitBit, Nike Fuel Band, Jawbone UP, and others would reside. Accelerometers provide data that includes step counts but also much more such as heart rate, calorie usage, and sleep tracking. I’ve also seen several startup companies with wearable accelerometers that can track in real time and on the field movement patterns of the legs and arms. My conclusion for the young athlete: possibly useful for the elite athlete. When movement tracking of body parts becomes available I think this will have broader usage, such as looking at arm position in pitchers or knee mechanics with jumping.

GPS devices

Global positioning satellites are used with your smartphones to provide data to apps that give directions, like Google Maps. GPS wearable devices are also increasingly popular with sports applications, especially for endurance sport athletes and monitoring of entire teams. Wearable GPS monitoring is becoming the norm for adult elite collegiate and professional teams, and I’m seeing it more and more at the high school level too. Conclusion: useful for the young endurance athlete, likely to filter into youth team sports too.

Physiologic Sensors

These devices track body physiology measurements such as heart rate, body temperature, and respiration. Professional teams are using these devices frequently, and individual endurance sport athletes use these as well. These measurements are useful and likely helpful for the athlete looking to peak performance but one caution is that you need to have some knowledge in how to interpret the data. For professionals, this is the job of their training staff. For the young athlete particularly in endurance sports such as triathlon, cycling, or distance running the information could be very useful but it would be important to work with an experienced coach to help you interpret the data. My conclusion for the young athlete: possibly useful in limited circumstances.

Overall these devices have the potential to be incredibly helpful for the elite level young athlete, and could have benefits for the recreational athlete too. Many of them have a very strong “coolness” factor. We need more data in establishing baseline levels for the young athlete and for sure you should work with someone skilled in interpreting the data you receive. But they are here to stay and will likely undergo further refinements over the coming months.



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

Key Points:

  • Blood Flow Restriction (BFR) training involves use of KAATSU bands or pressure cuffs to temporarily restrict blood flow during resistance exercises
  • This type of training is reported to substantially increase the strength of the involved limb much more than resistance training alone, and in a much shorter time
  • NCAA D1 and professional sport trainers in the U.S. are using BFR more often now, particularly after conditions such as ACL surgery
  • I’m cautiously optimistic that this training could be a breakthrough method to improve strength but would like to see much more research on safety and effectiveness in recreational athletes

I wrote last week about the benefits of High Intensity Interval Training (HIIT) as a way to get fit aerobically and anaerobically in the shortest amount of time. I love the efficiency of HIIT and continuing the efficiency theme this week I’d like to briefly explore a very different type of training, Blood Flow Restriction (BFR).

Blood Flow Restriction exercise was first used by Dr. Yoshiaki Sato in Japan in the mid 1960s. He later patented his treatement, called KAATSU. This exercise involves performing low load resistive training while blood flow to the working muscles is partially restricted by a pressure cuff or KAATSU bands. Evidence collected over the past decade suggests that performing low-load exercise with modest BFR to the exercising muscles serves as a potent stimulus for increasing muscle mass, strength, and endurance. The beauty of BFR training is that it’s reported to work much better and faster than resistance training alone.

As an orthopedic surgeon I have to admit that when I first heard about BFR training I thought it was crazy. There are a several very serious conditions that can result from occlusion to the muscles themselves, such as compartment syndrome and rhabdomyolysis. But somehow the BFR methods, involving short duration lower amounts of restriction result in temporary restriction of the blood flowing back to the heart through the veins and apparently doesn’t result in pressure increase in the muscles.

There’s increasing research into the mechanisms and results from BFR training. Some researchers have found that BFR can result in a slowdown of the gene contributing to muscle breakdown, up-regulates another gene contributing to muscle growth, and decreases muscle Ph (physiologists say this is a good thing if you’re builiding muscle…).

I recently attended a symposium on the state-of-the-art on rehabilitation after knee ACL reconstruction where BFR training is being used by more and more NCAA Division 1 programs and many professional teams. Like many treatments utilized by elite athletes I expect this will find it’s way into the training methods of adult amateur athletes and eventually young athletes.

This is potentially exciting stuff, well worth following. Even though the method has been SideLineSportsDocaround for about 50 years it’s somehow now gaining a foothold in the rehabilitative and athletic performance communities. I’d like to see a lot more research into the safety and effectiveness for use in recreational athletes so for now I’d recommend we approach this with cautious optimism.