Protecting the Growing Arms of Little League Pitchers

By John Graehler, P.T., O.C.S.

The score is tied in the top of the sixth inning; your son is pitching the game of his lifetime. After throwing five masterful innings, he has positioned his team to win the league championship game. He has faced 18 batters and has thrown 75 pitches. Do you, as a coach or a parent, let him finish the game or put in your reliever? As we begin another season of Little League Baseball, hundreds of pitchers will take the mound with dreams of becoming the next Roger Clemens or Pedro Martinez and possibly someday winning the World Series. At what cost?

Baseball pitching injuries are most commonly due to the accumulation of micro-trauma from the repetitive pitching motion. Pitch count, pitch type and pitching mechanics have found to have significant correlations with injuries to the elbow and shoulder during throwing activities. With our bodies' ability to generate up to 7,000-degrees/second angular velocity at the shoulder and 2,500-degrees/second at the elbow while throwing a baseball, the potential for overuse and injury can be quite prevalent. Add to that the fact that prepubescent boys are skeletally immature, which can lead to stress fractures at their growth plates. These types of injuries can disrupt bone growth and take an average of four to eight weeks to heal, potentially putting your ace pitcher out for a large part of the season.

CUMULATIVE PITCH COUNTS

The USA Baseball Medical & Safety Advisory Committee recommends limits of 52 + 15 pitches per game for 8-to-10-year-old pitchers, 68 + 18 for 11-to-12-year-old pitchers, and 76 + 16 for 13-to-14-year-old pitchers.

Dr. James Andrews, from the American Sports Medicine Institute, states, "We should also closely monitor the cumulative number of pitches thrown in a season." His research has found a steadily increasing risk for elbow pain up to the 601- to 800-pitch level. For shoulder pain, this steadily increasing risk went beyond the 800-pitch level.

With the increasing prevalence of Select, AAU and All-Star teams, as well as year-round leagues, this issue presents a multitude of potential problems. Who is keeping track of the cumulative pitch and inning counts each day, week and season? Who is looking out for the 9-to-14-year-old pitchers who do not know any better than what they are told by their coaches or parents? With the increasing desire to win at all costs, many of these pitchers are being put at risk for overuse and abuse to their shoulders and elbows.

PITCH TYPE

Pitch type has also demonstrated a significant correlation with elbow and shoulder pain while throwing. Most Little League pitchers start by learning a fastball and a change up. Curveballs and sliders can also be found in some pitchers throwing arsenals. Sliders, being the least commonly used of the mentioned pitch types, increase the risk of elbow pain by 86 percent. Use of the curveballs accounts for a 52 percent increase in risk of shoulder pain, without variation by age group. Use of a change-up pitch is associated with a 12 percent reduction in the risk of elbow pain and a 29 percent reduction in the risk of shoulder pain. It is suggested that curveballs and sliders not be thrown until 14 to 16 years of age because of the growth plates in the elbow and shoulder remaining open and therefore more susceptible to stress-related injuries.

PROPER PITCHING MECHANICS

Poor pitching mechanics have been blamed for many injuries related to the elbow and shoulder. Weakness in the legs, trunk, shoulders or arm muscles can lead to a breakdown of proper throwing mechanics. Preseason strengthening and endurance programs can be beneficial to help avoid mechanical breakdowns out on the mound. These programs should include aerobic activities, core and extremity strengthening and flexibility exercises. Running, cycling and swimming have been shown to increase cardiovascular potential and endurance. Specific exercises such as lunging, abdominal curls, resisted trunk rotations, scapular stabilization, rows and wrist curls help prepare the athletes for the stresses to come during the season.

Keep in mind that pitchers endure high repetitions while on the mound. When exercising, using low resistance and a high number of repetitions may better prepare them to "go the distance." Attaining and maintaining good flexibility in the shoulders, trunk, hips and legs can also assist in balancing the stresses of pitching and help prevent injuries from occurring. Most pitchers who have been trained to throw properly will not breakdown their mechanics until they become tired or fatigued. At this point, the pitcher should be relieved of his duties and allowed to rest.

APPROPRIATE REST

MRI (magnetic resonance imaging) studies have shown intramuscular swelling in the rotator cuff muscles for up to 96 hours (four days) following "all-out" pitching efforts. Appropriate rest times are essential in allowing the structures used in the throwing activity to recover and heal. Premature return to the throwing activity can result in further breakdown of the muscle, tendon and joint structures causing injury to occur. Tendonitis, bursitis, muscle strain, stress fractures, labral tears and shoulder instabilities are common with overuse-type throwing injuries. Most of these can be treated conservatively, but some are potentially career ending or may require surgery to repair torn tissues. Current Little League rules require three calendar days of rest if a pitcher throws four or more innings and one day of rest if a pitcher throws less than four innings. A player may pitch in a maximum of six innings in a calendar week. It is imperative that we, as coaches and parents, ensure proper resting times for our young athletes to protect them from the potential injuries from overuse and abuse.

With the ever-growing need for players to play for multiple teams, either simultaneously or throughout the entire year, we, as coaches and parents, must pay close attention to pitch counts, pitch types and closely watch to see when our pitchers mechanics begin to breakdown. Monitoring all of these factors can help coaches and parents in strategically ensuring a more successful season and a safer future for their players in baseball. Preseason and in-season strengthening, stretching and aerobic exercises are necessary to help prepare our players for the rigors and physical demands of the season. Finally, we must not forget why our players are playing the game.

References:

1. Andrews JR, Fleisig GS: Preventing throwing injuries. J Orthop Sports Phys Ther 27: 187-188. 1998
2. Oberlander MA, Chisar MA, Campbell B: Epidemiology of shoulder injuries in throwing and overhead atheletes. Sports Med Arthrosc Rev 8: 115-123, 2000
3. Lyman S, Fleisig G, Andrews JR, Osinski E: Effect of Pitch Type, Pitch Count, and Pitching Mechanics of Risk of Elbow and Shoulder Pain in Youth Baseball Pitchers. Am J Sports Med Vol 30(4): 463-8, 2002
4. Wick HJ, Dillman CJ, Wisleder D et al: A kinematic comparison between baseball pitching and football passing. Sports Med Update 6:13, 1991
5. Yanagisawa O, Niitsu M, Takahashi H, Itai Y: Magnetic resonance imaging of the rotator cuff muscles after baseball pitching. J Sports Med Phys Fitness. 43(4): 493-9, 2003
6. Official Regs and playing Rules. Little League Baseball. 33-4, 2004

John Graehler, P.T., O.C.S., is a vice president and clinical director for Kentucky Orthopedic Rehab Team. He has 15 years of experience specializing in orthopaedics, sports medicine and industrial rehabilitation. John has also coached in the St. Matthews Little League since 1999. Specific questions can be addressed to jgraehler@kort.com or by calling 502-964-5404.