By Barry Werries, MD
Board Certified Orthopedic Surgeon
Of all the athletic activities studied, throwing a ball creates one of the greatest forces across the elbow and shoulder. These repetitive forces make the shoulder and elbow susceptible to both acute and chronic overuse trauma. The incidence of baseball pitchers having shoulder or elbow pain is becoming an epidemic.
Even though the most common symptom is pain, there are other subtle signs and symptoms of an arm injury, such loss of strength and range of motion. The elbow or shoulder can have catching or locking or the player may have numbness in the arm. The player may have ball control problems or decrease in ball velocity. There may be changes in the mechanics which may actually cause damage somewhere else in the body. Other signs of fatigue may be an upright trunk or dropped elbow during pitching or increased time between pitches.
Risk factors for these injuries are the amount of pitching and pitching while fatigued. Other risk factors include pitching on multiple teams, pitching year round, playing catcher when not pitching, poor pitching mechanics, increased ball velocity, and poor physical conditioning. Injuries to the back or legs or loss of flexibility can alter the chain of events that contribute to the act of throwing and put more stress on the arm.
When a child who is not skeletally mature is exposed to throwing, the body will make some anatomic adaptations at the shoulder that may be protective. Although it is apparent that there should be a limit to the number of pitches to decrease injury, there may be an increased likelihood of injury in athletes who start pitching in high school than those who have been throwing in early childhood.
The USA Baseball Medical/Safety Advisory Committee has made recommendations on the limits of the number of pitches. Some organizations such as Little League Baseball have instituted these limits into their rules. These limits should also include pitches in practice, and coaches should be aware of pitch counts with players who play on other teams. Just as important as the number of pitches, the same committee has also made recommendations on days of rest after pitching. I am a firm believer that the body needs time to recover from the stresses of pitching, and I do not advocate throwing every day. Despite the emphasis on pitch count in a game, there is also evidence that the accumulation of pitches within a season is just as important to the health of the throwing arm. It is recommended to avoid any overhead throwing for 2-3 months per year and no competitive pitching for at least 4 months per year.
Unfortunately, little leaguers are throwing breaking balls at the age of 11 or 12. There has been a higher incidence of shoulder pain with curveballs and elbow pain with sliders. With proper mechanics, the curveball may not put increased stress on the elbow. Many young pitchers, however, have difficulty with the proper technique to throw a curveball, so there should be more emphasis on throwing a changeup at a young age. A safe approach is to wait until the age of 14 to start throwing curveballs and the age of 16 for sliders.
Proper throwing mechanics are very important to preventing arm injuries. Even though a pitcher is successful in games, throwing with improper pitching technique is like an engine leaking oil; the arm will eventually break down. If a pitcher does not correct his mechanic flaws, then his injuries will recur despite even surgical repair. Thus, it is advisable to have a coach who is knowledgeable of the proper throwing mechanics to work with a pitcher.
A majority of the throwing injuries occur in the beginning of the season because the players have not built up their strength. An excellent program for strengthening the arm is the Thrower’s Ten Program which focuses on the rotator cuff, scapular stabilizers, and forearm muscles. Many of the throwers who have arm problems have scapular dyskinesia. Scapular dyskinesia is when the scapula or shoulder blade is moving abnormally which creates shoulder/arm dysfunction and injury.
Many athletes focus on arm strengthening but they ignore the core/trunk and lower body strength which accounts for more than 50 percent of the kinetic energy to throw a ball. Core trunk stabilization focuses on strengthening the spinal and pelvic stabilizers and abdominal musculature. Weakness of lower body muscles, especially the hip abductors and hamstrings, have been identified in athletes with shoulder and elbow injuries. It is also important to build up the endurance of the lower body, and I prefer an interval sprinting program over jogging for baseball players.
The loss of flexibility of particular joints in the throwing athlete will predispose them to arm injuries. In the shoulder, throwing athletes have the loss of internal or forward rotation which is addressed by stretching the posterior, or back, of the shoulder. Care should be taken when stretching the front of the shoulder because most overhead athletes have stretched out their anterior capsule, which is in the front of the shoulder. In the lower body and trunk, the lumbar (low back) inflexibility, hip rotation deficit and hamstring tightness can also increase the risk of arm injury. It is also recommended to stretch for 5 minutes after playing.
In summary, a pitcher should focus on proper throwing technique, good physical conditioning and flexibility, avoid excessive stress on the arm and allow the arm to recover from the stress of throwing will help decrease the chances of an arm injury.
This article was published in the October-December 2014 edition of ”FYI from OCI”, a quarterly publication created by the Orthopedic Center of Illinois. To see the full publication, click HERE.