Preventing Throwing Injuries in Young Athletes

Youth sports have come a long way from the days when kids played on local Little League or Pee Wee teams once a year for short seasons. Even elementary-aged kids are playing increasingly competitive sports, often year-round, which can be tough on their small, growing bodies.

One of the most common injuries for youth athletes is caused by overuse or injury during the act of overhand throwing, most often seen in baseball or softball. We talked to Dean Papaliodis, M.D., orthopedic surgeon and physician on the medical staff at Texas Health Fort Worth and Orthopedic Specialty Associates, a Texas Health Physicians Group practice, about throwing injuries in young athletes, why they occur and what parents need to know.

“The rates of throwing injuries are rising as a result of overuse, inadequate rest with single sport specialization and poor mechanics, to name a few reasons,” Papaliodis says. “There has been a trend from adolescents participating in multiple sports with cross training to a single-sport specialization with year-round involvement. With this change, there has been an increase in overuse injury as the body presumably doesn’t have adequate time to recover from the demands of repetitive throwing.

“There has also been a change in the knowledge of throwing injuries and an understanding that throwing is a full-body action. With this knowledge, new paradigms of treating throwers have come about, focusing on non-operative management. These new ideas address issues in throwing mechanics, as well as kinetic chain imbalances in the anatomic structures involved in throwing.”

The action of pitching a baseball includes five steps: wind-up, early cocking, late cocking, acceleration and follow-through. When this movement is performed over and over at a high rate of speed, it puts substantial stress on the growth areas of the elbow and the anatomical structure of the shoulder, especially in the late cocking and follow-through phases.

For younger athletes, guidelines have been developed to help Little League coaches and parents determine the ideal number of pitches per game and week and how much rest he or she needs before returning to the mound based on the athlete’s age. Proper technique and conditioning (stretching and upper back and torso strengthening) and adequate recovery time between games can also help prevent injury.

As a parent, what are the warning signs that your athlete may be injured?

• Is she experiencing pain?

• Is his shoulder stiff? Can he rotate his arm in all the normal positions?

• Does her shoulder feel like it could pop or slide out of socket?

• Does his elbow “lock up?”

• Does she lack strength she previously had?

Athletes playing at higher levels and/or highly competitive athletes, may try to continue to play despite an injury. They may also underestimate their injuries because they have learned to play through pain, weakness and limited range of motion.

“Parents should be looking for any symptoms of pain or discomfort,” Papaliodis says. “Additionally, if an athlete appears to be struggling in his/her sport (i.e., “lost his stuff”), it may be a sign of overuse or injury. Athletes should be encouraged to make coaches and parents aware if something seems off and not just play through it. Often, trying to play through pain will lead to more severe injury and increased time off from sport in having to recover, or even require surgery.”

Despite an athlete’s best efforts to prevent injury, he or she may still experience pain or problems. At that point, a visit to the orthopedist is likely in order.

Papaliodis says the first evaluation goes a long way toward determining the problem and how to best address it.

“I explain to the patient that throwing is a whole-body motion,” he explains. “During my initial evaluation, I not only focus on the shoulder or elbow that is in pain, but also on other areas that need to be considered. This would include landing leg mechanics, quadriceps weakness, landing in stance, motion loss in the leg and hip, lumbo-pelvic-hip malalignment, core strength deficiencies, scapular malposition/strength and shoulder/elbow motion loss.

“We discuss what types of pitches are being thrown and the velocity of the pitch, how often the athlete is pitching (including his or her pitch counts) and what level of sport they are (high school, club, college, professional). We also discuss the importance of good pitching mechanics and if they are injured, the necessity of working with a therapist or trainer that has knowledge of throwing injuries inclusive of the kinetic chain.”

To examine an athlete’s issues, his or her physician will rely on a discussion of symptoms, a physical examination (range of motion, strength, stability, etc.), and if necessary, imaging tests such as X-rays, magnetic resonance imaging (MRI), computed tomography scan (CT) and ultrasound to determine the presence and severity of internal injuries. Treatment options may include activity modification, ice, anti-inflammatory medication, physical therapy, change of position, change of throwing technique and/or cortisone injections.

If non-surgical treatments for the shoulder aren’t successful, an athlete’s physician may recommend arthroscopy or surgery. Athletes with severe elbow issues may need bone fragments surgically removed, bones grafted or ligaments reattached to the bone. One of the most well-known surgeries common to pitchers is ulnar collateral ligament reconstruction, more commonly known as Tommy John surgery.

“The ulnar collateral ligament reconstruction of the elbow or ‘Tommy John surgery’ has been a revolutionary surgery that has allowed pitchers to continue participating in sports,” Papaliodis explains. “Prior to surgery, patients should have an understanding that the recovery process is a lengthy one. While most people believe it is a year-long recovery, it can actually take up to 18 months in order to progress through the rehabilitation process and throwing program prior to returning to full sport safely.”

Papaliodis says the surgery and recovery process is a step-by-step progression.

“The surgery itself is one that involves replacing a torn ligament with a tendon graft that can be harvested from the arm or the leg,” he says. “Additionally, if there are ulnar nerve symptoms or nerve instability in the arm, additional surgery may be required to address it. After surgery, the patient is generally in a splint for 10 days to two weeks and then transitioned to a brace.

“Motion recovery is the next step, along with progressive strengthening. No throwing is allowed in the immediate phase to allow for graft healing and wound recovery. As the patient progresses through the rehab process, a throwing program is started with specific steps working toward a return to throwing. There are additionally different throwing programs for softball versus baseball athletes after shoulder or elbow surgery.”

While physical therapy and rehabilitation play a significant part in returning an athlete to his or her previous activities, Papaliodis warns against unrealistic expectations.

“There is a common misconception that Tommy John surgery will make you throw harder or faster, but this has not been proven to be true,” he says. “To understand this, you have to understand how the injury manifests. More commonly, these tears are due to chronic wear over time that damages the tendon in a progressive fashion. As a pitcher’s ligament continues to deteriorate, his or her velocity decreases.

“Pitchers may originally be throwing 95 miles per hour, but then over the course of the next two years as the tendon damage progresses, velocity may decrease to 90 until finally the ligament tears. After the surgery, anatomy is restored so they may be able to pitch back at 95 mph, but it’s simply returning them to the same pitching speed as when they were healthy.”

The AOSSM offers sport-specific injury prevention tips for youth athletes here. To learn more about sports injuries, visit TexasHealth.org/SportsMedicine. To find an orthopedic surgeon or sports medicine specialist in your area, visit TexasHealth.org/Find-A-Physician.

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