STRIKE!

Looking behind the baseball at UCL injuries … and the role former Los Angeles Dodgers pitcher Tommy John plays

 

The goal of every great baseball pitcher is to strike out the batter.  To do this requires not only talent but extreme power every…single…pitch.

Few other athletes are required to throw with this kind of power as frequently as a pitcher.

Over the course of a baseball career, particularly if begun at a young age and played competitively, this high speed force repeatedly placed on the elbow can take a toll.

Often beginning with Little Leaguer’s Elbow, a condition affecting young pitchers who do not allow adequate rest between pitches, a baseball player’s elbow joint absorbs a tremendous amount of repetitive stress over the seasons.  The impact of this type of overhead throwing irritates the tendons and ligaments supporting the elbow joint, predisposing pitchers to more serious problems.  One such injury is an Ulnar Collateral Ligament (UCL) injury.

Once seen primarily in adult athletes, the dramatic increase in more serious overuse injuries like UCL damage, Flexor Tendinitis and Valgus Extension Overload (VEO) in young players prompted the American Sports Medicine Institute (ASMI) and the USA Baseball, Little League Baseball and Major League Baseball organizations to establish Pitch Count Guidelines.

While these changes and educational efforts are expected to reduce the number of overuse injuries seen in young players, competitive league players remain at risk.

Ulnar Collateral Ligament (UCL) Injury

Elbow Anatomy and UCL Injury

The Elbow Joint and location of the Ulnar Collateral Ligament

The ulnar collateral ligament (UCL) is among the most commonly injured ligament in throwing athletes.  To accommodate the high speed throwing motions, the ligament stretches and lengthens until it can no longer hold the elbow bones tightly enough. Severity of the injury can range from a sprain with minor damage and inflammation to a complete tear.

Symptoms Include:

baseball bullet

Pain on the inside of the elbow

baseball bulletA feeling of instability in the elbow

baseball bulletLoss of strength in throwing

baseball bulletIrritation of the ulnar nerve (funny bone) causing numbness in the small and ring fingers

Diagnosis and Treatment

A UCL injury is diagnosed based on the results of a physical examination, X-ray and MRI.  Depending on the severity of the damage, rest and refrain from play along with rehabilitative exercises and anti inflammatory medication may be indicated. Work with an athletic trainer may also be helpful, to assess throwing mechanics and improve body positioning which can reduce excessive stress on the elbow.

If there is a complete tear of the ligament and patients fail to improve with conservative treatment, surgery may be indicated.

The UCL reconstruction procedure, which was performed on former Los Angeles Dodgers pitcher Tommy John and is more commonly known as Tommy John surgery today, has dramatically changed the outcome for athletes.  In fact, his results were so impressive, it is reported that young players not actually suffering from a UCL injury have sought Tommy John surgery in hope that it would improve their performance [1]!  The procedure, though, is performed only when necessary to repair a severely torn UCL.

Tommy John surgery is a surgical graft procedure in which the injured UCL is replaced with a tendon graft taken from the forearm or the hamstring tendons.  This procedure is followed by an intense rehabilitation program that lasts from six months to a year, depending on the position an athlete plays.  Throwing exercises can begin in about 16 weeks.

The Role Tommy John Continues to Play

In the medical community, Tommy John remains credited with the shift in how athletes view UCL injuries. Once career ending, today UCL reconstruction has become a common procedure – returning most athletes to their sport at a pre injury level of play.

In the sports world, Tommy John is still revered for the excellent athlete he was, choosing baseball as his sport of choice and playing in all three of the Yankees vs Dodgers World Series in his era (1977, 1978 and 1981).

Undergoing the procedure in 1974 and spending his entire 1975 season in recovery, he learned to pitch in a way that relieved the stress he was placing on his arm and leg.  He returned to the Dodgers in 1976. His 10-10 record that year was considered “miraculous.”  But, he went on to pitch until 1989 winning 164 games after his surgery – just one game shy of baseball great Sandy Koufax.

The recognition he received for his unexpected success following the procedure now donning his name became the launching pad for other endeavors benefiting young baseball players.

His “Let’s Do It” foundation, which umbrellas the Tommy John Pitching Academy, is today dedicated to research in preventing such injuries and teaching pitching techniques that minimize the physical impact. The foundation also supports the efforts of the American Orthopedic Society for Sports Medicine (AOSSM) and its collaborators’ STOP Sports Injuries Campaign as well as the American Foundation of Suicide Prevention (AFSP).  AFSP and its outreach effort is an important component in the foundation’s efforts in memory of his son.

 References

  1. Longman, Jere. Fit young pitchers see elbow repair as cure-all. 2007 Jul.

 

 

Baseball Fit – Preventive Exercises for a Winning Season

As weather warms and winter sports wind down, attention turns to the promise of a new baseball season and the championships ahead.

Now is the time to begin preparing.High School baseball

At the core of a successful team are strong players – physically strong, well rested and well conditioned.

Baseball is one of the few sports played almost daily throughout the entire season.  For young players beginning in little league, this amounts to a lot of plays by high school.  The frequency of repetitive stress injuries in youth baseball have increased over the years, particularly with the rise in special “elite” teams and extended seasons. This is most evident in young pitchers, on which much research has focused and for which Pitch Count guidelines have been developed.

Although baseball is not considered a contact sport, injuries can result from contact with the ball and other players, as well as poor form/technique, or an awkward movement during a play.

Some of the most common baseball injuries include:

  • Injuries in the shoulder and elbow (Little Leaguer’s Shoulder, Little Leaguer’s Elbow)
  • Knee injuries
  • Muscle pulls
  • Ligament injuries
  • Fractures (Finger, Distal Radius/Wrist)
  • Concussions 

While some injuries resulting from collision with another player are getting hit by the ball cannot be avoided, exercise can aid in reducing risks or preventing many repetitive stress related injuries.

Repetitive injuries are the result of repetitive use, stress and trauma to the soft tissues of the body (muscles, tendons, bones and joints), which are not given adequate time for proper healing. They are sometimes called cumulative trauma, repetitive stress or overuse injuries.

To avoid such repetitive stress conditions and muscle fatigue, players should have a dedicated fitness program – ideally one that is also specific to the position they play.  This should include overall strengthening and endurance, along with specific exercises to equally strengthen the muscles of the limb(s) most used. Such fitness programs should also include stretching and rest between play.

Exercise programs should also be age appropriate. Young, developing players are encouraged to build strength through resistance rather than weights. Involvement in other seasonal sports such as swimming and running can also provide excellent overall strengthening and endurance.

Strength and Conditioning Exercises – Upper Body

As a throwing sport, exercises for baseball concentrate heavily on the upper body – arms and shoulder. Core strength is also essential for pitching velocity, hitting power and running speed.

The key to any exercise program is the balanced/equal strengthening of muscle groups. For the upper body, this includes triceps/biceps, trapezius, rotator group, and deltoids.

Some Effective Arm, Shoulder and Core Exercises Include:

  • Resistance bands – These can be effective in building arm and shoulder strength. (View video on how these bands are used in exercise programs.)
  • Push ups – Traditional push ups are very effective in building upper body strength (arms, shoulders, back and core/abdominal muscles).
  • Pull ups – Using your own body weight/strength these work on the biceps, upper shoulder and back, upper abdominals and obliques.
  • The Plank – strengthens the core, lower back and oblique muscles. (View video demonstration of the Plank.)

Exercises to Improve Leg Strength

Lower body strength and conditioning is as important as upper body training for young athletes. Leg strength impacts throwing velocity, bat speed/force and running speed.

Squats, lunges and running are among the most effective ways to strengthen the lower body.

Stretching

Stretching is a very important part of an exercise program for athletes in any sport. During exercise and play muscles contract. When muscles contract, they produce tension at the point where the muscle is connected to the tendon. Stretching helps lengthen, relax and restore muscles to their natural state.

Stretching following activity is as important as stretching while warming up before practice and play.

Some easy, yet effective stretches include:

  • Elbow Pulls – Raise the right arm as though asking a question and drop the forearm behind the head though leaving the elbow in the air. Pull the elbow to the left with the left arm until you feel the stretch, hold briefly then repeat several times. Do the same on the opposite side.
  • Cross Body Arm Pulls – Straighten your right arm and pull it across the front of your body, cradling the forearm and elbow with the left hand, pull the arm towards the left across the body until you feel the stretch. Hold the stretch briefly, then repeat on the opposite side.
  • Shoulder Stretch – Lay face down on a floor mat and stretch arms overhead to form a “Y,” with palms facing down on the floor. With forehead on the ground, retract shoulder blades while lifting arms off the ground (still outstretched). Hold for a couple of seconds while squeezing the shoulder blades together. Be careful not to “shrug” the shoulders up. Return to starting position and perform several sets of 10 repetitions. To work the back a little differently, perform this same exercise with the arms straight out to your sides, forming the shape of a “T.”
  • Runner’s Lunge – Position into a deep lunge on your right leg, drop the knee of your left leg and lean forward over the right quad until you feel the stretch, hold for several seconds. Repeat on opposite leg.
  • Hamstring Stretch – Stand flat on the floor with feet a little less than hip width apart. Lean forward and place palm of your hands flat on the floor just in front of your feet, hold for several seconds.

TOP PREVENTION TIP

Resting is as important as any of the components in a successful training program.

Keeping Young Players in the Game This Season …. and the Next

Pitch Count Guidelines and Little League Recommendations

Last month we discussed the increase in injuries among Little Leaguers – particularly the prevalence of “Little Leaguer’s Elbow.”  We continue this discussion in this month’s blog with some of the things that the American Sports Medicine Institute (ASMI) and the USA Baseball, Little League Baseball and Major League Baseball organizations have done to ensure the safe play of our young athletes today….and tomorrow.

Avoiding little league injuries.

Pitch count regulations developed to reduce risk of injury in young players.

 New Recommendations

While curve balls are implicated in throwing injuries of the young athlete, because of inadequate physical development and neuromuscular control, scientific data does not yet support this.  Nonetheless, reducing the use of curve balls in Little League pitching is highly recommended.

Other recommendations include: 

  • Watching and responding to fatigue (decreased ball velocity/accuracy, upright trunk during pitching, dropped elbow during pitching, or increased time between pitches). If a youth pitcher complains of fatigue or looks fatigued, let him rest from pitching and other throwing.
  • No overhead throwing for at least two to three months per year (four months is preferred). No competitive baseball pitching for at least four months per year.
  • No pitching more than 100 innings in games – in any calendar year.
  • Follow limits for pitch counts and days of rest.
  • Avoid pitching on multiple teams with overlapping seasons.
  • Learn good throwing mechanics. First steps should be, in order: 1) basic throwing, 2) fastball pitching, 3) change-up pitching.
  • Avoid using radar guns.
  • A pitcher should not also be a catcher. The pitcher-catcher combination results in many throws and may increase the risk of injury.
  • If a pitcher complains of elbow or shoulder pain, discontinue pitching until evaluated by a sports medicine physician.

Pitch Count

The pitch count restrictions for Little League Baseball were established to reduce the number of overuse throwing injuries among these young players and vary by age.  While the complete pitch count restrictions/recommendations can be reviewed on the ASMI website (www.asmi.org ), below is a listing of the latest Little League “daily” limits.

Daily Limits
17-18 N/A 105/day
15-16 N/A 95/day
13-14 75/game 95/day
11-12 75/game 85/day
9-10 50/game 75/day
7-8 N/A 50/day

(Resources – recommendations and pitch count: American Sports Medicine Institute, Position Statement for Youth Baseball Pitchers http://www.asmi.org/research.php?page=research&section=positionStatement

 

Little Leaguer’s Elbow

With baseball season in full swing we begin to see an increase in upper extremity injuries in young athletes. One of the most common injuries we treat is a throwing injury known as medial apophysitis, or “Little Leaguer’s Elbow.”

This condition occurs when the repetitive stress of frequent throwing places excessive strain on the tendons, ligaments and cartilage of the elbow joint.  In the young player and immature elbow this is particularly concerning because of the damage it can cause to the growth plate.

The two “phases” of throwing which impact the elbow joint include the early acceleration phase (a pulling force on the growth plate of the inner elbow) and the throwing/release phase (strong inward and downward snap of the wrist).  A hinge and pivot joint, the elbow allows a broad range of motion.  The growth plate in the elbow, though, is comprised of growth cartilage – a soft substance that is not as strong as bone.  With repetitive stress, this growth cartilage can weaken, develop small fissures and in more severe cases pull apart from the bone. The repeated pulling can also tear ligaments and tendons away from the bone – possibly pulling tiny bone fragments with it.  In a young player, this could potentially disrupt normal bone growth and result in deformity.

Another less common though more serious throwing injury, known as Osteochondritis Dissecans, can occur in young athletes and involves the loosening and fragmenting of immature bone and cartilage. The pain associated with this condition is usually felt on the outside of the elbow.

Both prevention and early treatment of Little Leaguer’s Elbow are key for young players.

Symptoms of Little Leaguer’s Elbow

The most common symptom associated with Little Leaguer’s Elbow is pain on the inside of the elbow, which may be severe and occur abruptly, or mild – increasing in intensity, gradually over time.  Other symptoms may include swelling, redness and warmth over the inner elbow.  Range of motion may be restricted in some players, with an inability to straighten the elbow.

Diagnosis and Treatment

A physical examination and pain assessment will help diagnose Little Leaguer’s Elbow.  An X-ray or MRI may be indicated to assess irregularities in the elbow joint and growth plate damage.

When diagnosed early, nonsurgical treatment can effectively resolve the problem and may entail rest (refraining from throwing activity), as well as icing to reduce swelling.  Sports rehabilitation specialists may also be able to help young players refine their throwing technique to reduce stress on the elbow joint.

In more severe cases, surgery may be required to reattach a ligament and/or the bone or growth plate  – stabilizing the elbow joint.

Preventing Throwing Injuries in Little League Baseball

Understanding the impact of throwing injuries on the immature elbow is key for coaches, parents and players.  Risk of injury can be reduced by properly warming up and ensuring proper throwing technique.  And adequate rest is as equally important as practice for optimal performance.

The American Academy of Orthopaedic Surgeons (AAOS) recommends that young pitchers play no more than three to four innings each game, to prevent throwing injuries.

Pitch Count Guidelines and Little League Regulations

As competition in youth sports intensify and seasons extend to include tournaments and World Series games, we are seeing an alarming increase in throwing injuries in the young player.  This has prompted the American Sports Medicine Institute, together with USA Baseball, Little League Baseball and Major League Baseball to examine the impact of excessive throwing on the young, skeletally immature athlete.  Their findings have translated into new regulations, pitch count guidelines and educational initiatives in Little League Baseball.

Next month we’ll talk about pitch count guidelines and its role in protecting young baseball players.