Home Blog Pitching Injuries: It’s Not Just What You’re Doing; It’s What You’ve Already Done

Pitching Injuries: It’s Not Just What You’re Doing; It’s What You’ve Already Done

Written on May 18, 2011 at 6:22 am, by Eric Cressey

A while back, this article on pitching injuries became the single-most popular piece in EricCressey.com history:

Your Arm hurts?  Thank Your Little League, Fall Ball, and AAU Coaches

In that feature, I made the following statement:

We can do all the strength training, mobility work, and soft tissue treatments in the world and it won’t matter if they’re overused – because I’m just not smart enough to have figured out how to go back in time and change history. Worried about whether they’re throwing curveballs, or if their mechanics are perfect?  It won’t matter if they’ve already accumulated too many innings.

While athletes might be playing with fire each time they throw, the pain presentation pattern is different.  You burn your hand, and you know instantly.  Pitching injuries take time to come about. Maybe you do microscopic damage to your ulnar collateral ligament each time you throw – and then come back and pitch again before it’s had time to fully regenerate.  Or, maybe you ignore the shoulder internal rotation deficit and scapular dyskinesis you’ve got and it gets worse and worse for years – until you’re finally on the surgeon’s table for a labral and/or rotator cuff repair.  These issues might be managed conservatively if painful during the teenage years (or go undetected if no pain is present) – but once a kid hits age 18 or 19, it seems to automatically become “socially acceptable” to do an elbow or shoulder surgery.

Sure enough, just yesterday, reader Paul Vajdic sent me this article from the Shreveport Times. The author interviews world-renowned orthopedic surgeon Dr. James Andrews about the crazy increase in the number of Tommy John surgeries he’d performed over the past decade.

A comment he made really jumped out at me, in light of my point from above:

“”I had a kid come in, a 15-year-old from Boca Raton, (Fla.), who tore his ligament completely in two,’ Andrews said. ‘The interesting thing is when I X-rayed his elbow with good magnification, he has a little calcification right where the ligament attaches to the bone. We’re seeing more of that now. He actually got hurt with a minor pull of the ligament when he was 10, 11, 12 years of age. That little calcification gets bigger and, initially, it won’t look like anything but a sore elbow. As that matures, it becomes more prominent. It turns into an English pea-size bone piece and pulls part of the ligament off when they’re young.'”

In other words, it takes repeated bouts of microtrauma over the course of many years to bring an athlete to threshold – even if they have little to no symptoms along the way.  Injury prevention starts at the youngest ages; otherwise, you’re just playing from behind the 8-ball when you start training high school and college players.

In addition to walking away with the perspective that young kids need to be strictly managed with their pitch counts, I hope this makes you appreciate the value of strength and conditioning programs at young ages, too.  For more information, check out my post, The Truth About Strength Training for Kids.

We can’t prevent them all, but I do think that initiatives like the IYCA High School Strength Coach Certification in conjunction with pitch count implementation and coaching education are a step in the right direction.

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  • That’s a good post.

    Personally I’m running into pitching coaches that want their kids throwing year round, and I want my guys to have healthy bodies.

    Thankfully I’m in Iowa where it gets too cold to play outside year round.

    What are your thoughts on pitch count/age level?

    Obviously a 14 year old kid doesn’t need to be learning a curve ball yet, but total pitch counts are a different deal. Especially when you consider a full week of practice, warm up, bull pens, most kids also play in the field until college, etc. What are your thoughts?

  • Once agian, Well said Eric. I once heard or read that the #1 predictor of an injury, is past injury. By that token, I can see why you would HAVE to consider all the asymptomatic microtruama that accompanies the high pitch count to be a predictor for future injury. It can never hurt to be pro-active with younger athletes, and can’t be stated enough.

  • James

    Echo the above comments, follow with a question–when to start strength training, and what to do? Clearly every child is different, and so are their experiences. A 12 year old playing rec ball has a completely different volume of potential trauma than a 9 year old playing 45-50 travel ball games in the spring season alone. Factor in physical and emotional maturity as wild cards and it’s hard to know as a parent when and what to do for your kids. Thoughts?

  • Eric – That is a great article. We have 2 kids on my select team (15 u) that finished High School and have arm injuries.

    You can also put blame on the parents. I’m seeing alot of kids that don’t have agility or speed.
    On my team we do a lot of speed & agility training, Sprint work, explosion jumps,jump rope,
    boxing (Heavy bag/Speed bag training for hands, and mental toughness). I started this type training when my son Ricky was 11 yrs old. This training made him the 1st Team All State Div.1 baseball player in Ohio 2009. He received scholarships offer from everywhere, and he’s only 5’4″. 2009 Buckeye Scout #31.

    I also think alot of parents, don’t understand how to train their kids, or haven’t played the game. I believe weight training is essential to a kids overrall development.

    Eric – You have lots of knowledge!

    Rick Finley

  • Solid post, Eric.

    I think the overwhelming factor has more to do with misuse (consistently poor technique) as opposed to overuse (pitch counts).

    You said:

    “Maybe you do microscopic damage to your ulnar collateral ligament each time you throw – and then come back and pitch again before it’s had time to fully regenerate.”

    What caused the UCL to microscopically tear? Repetition, possibly. Incorrect technique, absolutely.

    I think it’s important to point out that once a player has UCL Replacement Surgery, the new UCL cannot regenerate due to zero blood supply. If that player resumes throwing using his old technique, it won’t be long before he destroys his replacement UCL.

    I’m not saying that overuse is something to dismiss, especially if we’re talking about youth ball players playing competitively 10-12 months out of the year. I mean, it’s great that Little Johnny won a trophy, but what motor skills or knowledge of the game has he developed in the process? What toll does does this year ’round season take on his physical maturation?

    The problem with overcoming the misuse factor: incompetent private pitching coaches. (I guess we could throw in team coaches as well.) If I had a nickel for every former pitcher telling kids “this is what worked for me,” while dismissing the zipper on his elbow as “part of the game,” an unfortunate accident, etc…

    In any event, you’re right on point. Despite what a certain closer-turned-expert on MLB Network believes, one pitch doesn’t create an injury. It takes time, (I forgot to mention poor conditioning!) and a consistently poor technique to develop a significant injury.

    Keep up the great work!

  • Very timely post, Eric, as Felipe Paulino just became the fourth KC Royals pitcher heading for Tommy John surgery this year.

    Do you think this is just bad luck, or is there that much difference between conditioning programs throughout major league baseball?

  • Greg,

    There are definitely differences throughout MLB. However, the Royals are one of the better ones; Ryan Stoneberg does a great job. Lots of these issues certainly pre-date anything he could have done to prevent them.

  • Karen S.

    Personally I see these guys playing with the “check engine” light on for a long time, sometimes years. Then it’s that one throw, or the next morning after pitching, they “feel something”. It’s bound to happen, even when they do everything right during the off season.

    There has been a plethora of TJ surgeries in MLB this year, and it’s only June. ‘Ol Dr Andrews has his hands full literally with these players, and a couple of them are coming back for “round 2”.

    I think it’s not only important that a proper strengthening and conditioning program is in place for these youngsters who desire to play in college (and beyond), but an emphasis on optimal flexibility to accompany with it, especially during those “growing years”. I’d like to hope, that with early flexibly training during the development years (along with the other good strategies in place) that somehow we can see a downturn in this disturbing trend.

  • Stretched ligaments do not heal properly even with rest – scar tissue formation occurs on ligaments resulting in weakened tissue. This may account for chronic joint instability, arthritis and pain. A strength training program is essential. The question is aside from technique, pitch counts etc, how can we heal damaged ligaments?

    Frank C, Woo SL, Amiel D, Harwood F, Gomez M, Akeson W. (1983). Medial collateral ligament healing. A multidisciplinary assessment in rabbits. The Journal of Sports Medicine, 11(6).

  • Eleazer Espinosa

    Great article. Lots of good information to recall for when my son gets into baseball and other sports. By the way, the link for the article from the Shreveport News does not work.

  • There’s the million dollar question, John! The healing will never be perfect, so they are really just kicking the can down the road until things reach threshold. To that end, the best treatment is prevention.

    There are still a few things we can address, namely improving anterior core stability, making sure lat doesn’t overpower the lower traps, and controlling anterior humeral head migration. These can minimize valgus stress slightly.

    Dramatically changing throwing mechanics is tough, as you run the risk of taking away exactly what makes guys successful. However, if you can work to get them to 90 degrees of elbow flexion or less at stride foot contact, you’ll reduce valgus stress as well.

  • As a parent of a 9 yr old ball player I recently watched a 10 yr old pitcher pulled from a game with his arm hanging limp – that was not the first time I saw this kid pulled from a game for shoulder/arm pain. The trickle down of information about pitching mechanics and sports injuries is too slow – the injury process starts at a young age. Ideally parents/coaches/players need better information about proper mechanics, injury identification and corrective measures. A simple video provided by the little league etc on pitching mechanics, self care/massage and strengthening exercises would be extremely helpful. Parents cannot rely on coaches to ensure the health and athletic skill development, at least on the little league level. A DVD would ensure proper info at least.


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