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.

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 Importance of Strengthening the Gymnast’s Elbow

By Tara Hackney, PT, DPT, OCS, KTTP for Atletico Physical Therapy

strengthening gymnasts elbowGymnastics offers a unique perspective, even allowing some athletes to see the world upside down!

Very few sports involve supporting the entire body weight with the arms like gymnastics. Due to these special considerations, gymnasts are more prone to certain injuries, such as Osteochondritis Dissecans of the elbow (OCD), and should take care to strengthen the entire arm to decrease injury risk.

What is OCD Elbow?

Osteochondritis Dissecans (OCD) lesions can be found in the elbows of adolescent athletes. The exact cause of OCD in the elbow is unknown, but repetitive microtrauma and decreased blood flow to the subchondral bone are believed to play a role. As the underlying bone weakens, a segment of the articular cartilage separates from the subchondral bone, forming a lesion. OCD lesions in gymnasts may be caused by repetitive weight bearing on the hands with the elbow in extension.

Presentation of elbow OCD is very vague. A patient can have pain, tenderness and swelling over the lateral aspect of the elbow. There may be limitation in how straight the elbow can go and there may be locking or catching if the injury has progressed. However, tendinitis of the elbow can have a similar presentation. More often OCD is suspected in specific patient populations including pre-teen and teenage gymnasts as well as young baseball pitchers with elbow pain. Diagnosis is through imaging such as x-ray or MRI.

Treatment for OCD Elbow

Non-operative treatment for elbow OCD consists of rest and sports restriction. For a gymnast that means no weight bearing on arms and no hanging from bars or rings as the latter puts traction stress through the elbow. Muscle strengthening exercises and possibly a short period of immobilization are also usually a part of treatment.

There are some cases where the lesion is unstable and surgery is the best option. After surgery, physical therapy is performed to reduce pain, swelling and restore range of motion. Resistance strengthening is also incorporated into the rehabilitation after bone healing has occurred, usually around 8 weeks after surgery.

What Can Athletes Do While Resting Their Elbow?

If a gymnast has been diagnosed with an OCD lesion, they are not allowed to do any weight bearing on the arm, which includes performing skills on the bars. So what can the gymnast do as they allow their elbow to heal? Core strengthening is one option, as core strength is vital to a gymnast and is important during all events. Leg strengthening can also be performed while adhering to the restrictions on the elbow. An overall conditioning program can be designed for the athlete that will incorporate cardio, core strengthening, leg strengthening, shoulder and wrist strengthening, and flexibility stretching. Staying active and in shape is vital to the gymnast during this time to assist in returning to the sport when the elbow restrictions are lifted.

Arm Strengthening for Gymnasts

The elbow is the middle joint of the arm with the shoulder and wrist on either side. While the gymnast’s elbow is healing, it is important to strengthen both of the surrounding joints to provide extra stability for the arm for when return to weight bearing is allowed. Prior to initiating any activities, ensure the gymnasts’ physician has cleared them for return to these exercises.

            Shoulder strengthening examples:

  • Resistance band exercises including rows, shoulder extension, diagonals, internal/external rotation
  • Sidelying shoulder external rotation
  • Tricep extension with band or hand weight
  • Bicep curls with band or hand weight
  • Prone I, T, Y exercises – exercises can be performed using a swiss ball for added core activation, hand weights can be added for resistance
  • Gradual return to weight bearing exercises, like push-ups, planks and handstands, can be added when the athlete is cleared from restrictions

            Wrist strengthening examples:

  • Wrist curls in both directions with a weight or resistance band
  • Gripping exercises for the hands
  • Wrist rotation exercises, such as hand weight rolling
  • Supination/Pronation with a hand weight

Arm Stretching for Gymnasts

  • Wrist flexor stretch
  • Wrist extensor stretch
  • Cross body shoulder stretch
  • Tricep stretch
  • Shoulder flexion stretch on foam roller, wall, or mats
  • Shoulder circles – lie on your side on the floor and draw a circle on the floor with your top arm by rotating your upper body
  • Doorway stretch

Strengthening the Upper Body

Gymnasts have special considerations due to the nature of their sport with weight bearing on the arms. This can lead to injuries of the elbow such as OCD lesions. Strengthening of the entire upper body, including shoulder and wrists, should be incorporated into a conditioning program for both healthy gymnasts and gymnasts recovering from an elbow injury.

For more information, contact an Athletico clinic close to you for a complimentary injury screening.

Schedule a Complimentary Injury Screen

Common Hand Injuries: Text Thumb; Little League Pitchers: Do’s & Don’ts; Importance of Sleep for Optimal Recovery

Episode 17.35 with Hosts Steve Kashul and Dr. Brian Cole. Broadcasting on ESPN Chicago 1000 WMVP-AM Radio, Saturdays from 8:30 to 9:00 AM/c.

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Segment One (01:10): Dr. Nik Verma sitting in this week for Dr. Cole joins Steve andImage result for thumb overuse Nicole Kauppila from Athletico Physical Therapy to discuss Tech Thumb injury.

Each year as we approach the holidays, smartphones are listed as a top gift.  With use of smart phones – tech-related injuries called “tech-thumb” resulting from unnatural movements like constant texting are on the rise.

New smartphones often means even more time straining thumbs, in fact young adults spend a staggering one-third of their waking hours on smart phones. Nicole describes causes, symptoms, prevention and treatment for overuse injuries of the hand.


 Segment Two (11:46): Dr. Nik Verma, Head Team Physician for the Chicago White Sox talks with Steve about how to avoid overuse throwing injuries in young athletes; avoid training in one sport all year long, high pitch velocity and pitch counts that can cause damage from repetitive load on the growth plates of young athletes.

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Segment Three (20:14): Todd Sayer, PT from ATI Physical Therapy talks about the importance of sleep for optimal recovery; the correct supportive neutral sleep position; avoiding compressed shoulder joint in side sleepers. 

How you sleep dictates how you perform, so whether you are falling short on logging enough sleep each night or poor sleep posture is inhibiting a solid day’s performance, making a few simple changes can help to enable a good night’s rest and support your body’s ability to adapt and adjust.

Todd Sayer  is a Senior Regional Director with ATI. He has 18 years of clinical experience specializing in treatment outpatient orthopedic and sports medicine injuries as well as chronic pain and post-operative care.

Overcoming Sleep Challenges and Discomfort

PITCH SMART RECOMMENDATIONS FOR YOUTH BASEBALL

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.