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.

 

 

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.