If your child is a pitcher, he/she has about a fifty-fifty chance of experiencing pain in his/her elbow or shoulder during his/her baseball career.
A 2001 study in the journal Medicine, Science, Sports & Exercise1 found that athletes who pitched with a tired arm were 6 times more likely to suffer from elbow pain and 4 more times more likely to have shoulder pain than those who did not have a tired arm.
A 2002 study in the American Journal of Sports Medicine2 found:
A 2006 study in the same journal3 found that overuse was the overriding factor in the development of arm pain among pitchers in youth baseball. That study identified the following risk factors for injury:
Elbow pain was related to:
Shoulder pain was associated with:
A 2010 study [4]5 by researchers at ASMI found that:
Other researchers have found that:
The epidemic of arm injuries suffered by youth baseball pitchers is reflected in the dramatic increase in the number of shoulder and so-called Tommy John elbow (ulnar) ligament-transplant operations [6] performed by Dr. James Andrews at ASMI:
Research by the ASMI and others points to three principal risk factors for injury to youth baseball pitchers: overuse (number of pitches during a game, season, and a year), poor pitching mechanics, and poor physical fitness/physical conditioning.
Of the three, experts seem to agree that the number of pitches thrown coupled with the lack of appropriate rest periods are the greatest contributor to the increasing incidence of pitcher arm injuries.
The 2010 ASMI study5 [4] suggests that it is the number of innings (greater than 100 in a calendar year) that puts pitchers at greatest risk of serious injury.
Likewise, a 2011 study [9]6 reported in the American Journal of Sports Medicine suggests that pitchers in warm-weather climates are increased risk for injury because of the excessive time they dedicate to pitching in a calendar year.
Finally, another 2011 study [5], this one by researchers at the University of North Carolina and commissioned by Little League, also found that the average number of innings pitched per game was a risk factor for shoulder injuries in youth baseball pitchers.
"The number 1 risk factor for UCL injuries is poor mechanics," Dr. Andrews told ESPN The Magazine [10]. "The No. 2 factor is overuse. And if you combine overuse with poor mechanics, you're doomed."
Other risk factors:
As a 2009 study by ASMI7 notes, like pain (see #8 below), "fatigue is generally difficult to quantify because it is a subjective measure that varies among persons." The study recommends using pitch counts, ball velocity, ball location, pitching mechanics, and strength as guides to determining fatigue.
Research shows that youth baseball pitchers who pitch competitively more than 8 months a year are 5 times more likely to require surgery than those who take at least a four month break from throwing.
This is particularly true for pitchers in warm-weather climates, who tend to play more months of the year than those in cold-weather climates. A 2011 study6 [9] found relative weakness of the rotator cuff of shoulders of warm-weather pitchers and an inverse and negative relationship between the number of months spent pitching and internal rotation range of motion and external rotation strength, The authors concluded that warm-weather pitchers were a "previously unrecognized, [but] vulnerable population in terms of their injury risk."
To reduce the risk of injury, youth baseball pitchers need a period of "active rest" after the baseball season ends and before the next season begins during which they should stay physically active to maintain conditioning, but refrain from overhand throwing of any kind:
The American Academy of Pediatrics' 2012 Policy Statement on Baseball and Softball14 likewise states that "Youth pitchers should not pitch competitively in more than 8 months in any 12-month period, and recommend 3 consecutive months of complete rest from pitching each year. (USA Baseball/MLB recommend at least 2 to 3 consecutive months off)
Based on research showing a strong link between the number of pitches thrown and increased risk of arm injury, Little League Baseball instituted daily pitch limits [13] and mandatory rest periods between pitching appearances in 2007, which it updated for the 2010 [14] spring season.
Dr. James Andrews of ASMI, perhaps the world's foremost authority on pitching injuries, hailed the Little League pitch limit and rest rules as "one of the most important injury prevention steps ever initiated in youth baseball," although he warns that pitch counts alone can't protect UCL's from poor mechanics (see #5 below).
USA Baseball [15]8 recommends pitch limits but does not mandate them. A 2012 study [16]13 found that knowledge of the pitch limits among youth baseball coaches, however, was poor, putting youth pitchers at increased risk for upper extremity pain and injuries.
The low percentages of coaches answering the pitching guideline questions correctly "are concerning, as it is quite difficult for coaches to accurately follow guidelines with which they are not familiar," noted the study.
In its 2011 position statement on overuse injuries [1],4 the National Athletic Trainers' Association recommends the following general limits:
There are currently no pitch-count limits in high school baseball, but Dr. Andrews believes there should be. "I have heard of kids who throw 160 pitches in a game, and that's just not safe," he told ESPN.com in a February 2012 interview. He also says pitchers should never pitch on back-to-back days.
A note of extreme caution to parents of youth baseball pitchers on independent travel and all-star teams competing in independently-operated tournaments: they may have NO rules at all on pitch limits and rest. Such travel, "elite" or "select" baseball programs have been subject to considerable criticism, including Little League's 2011 study [5] on pitching injuries.
Dr. Andrews identified travel ball as a big cause for fatigue because coaches from different teams do not communicate with each other. "One coach will pitch a kid for five innings one night and then the next day the same kid will go throw five more innings for a different coach in a different game," Andrews told ESPN.com. "These pitchers should not be playing in more than one league at once. You have to rest to prevent these injuries."
If parents allow their child to play on more than one team at a time (see #4), it will likely be up to parents [3] to track their child's pitch counts so they don't exceed recommended limits.
The 2012 study13 [16] showing poor knowledge of the USA Baseball pitching limit recommendations only makes monitoring by parents all the more critical. Statistics recently published by Safe Kids International found that nearly half (45%) of youth baseball pitchers pitched in a league with no pitch limits, nearly as many (43.5%) pitched on consecutive days, and 19% pitched multiple games on the same day.
More and more youth baseball players play on multiple teams at the same time. While doing so may give him/her more opportunities to develop his skills, and while the amount of pitching may be limited by league rule or the judgment of the coaches, playing on multiple teams with overlapping seasons increases the risk that he/she may end up exceeding pitch limits (or the 100 inning limit recommended by ASMI in its 2010 study [4]5) because of a lack of communication and coordination between coaches, who are likely to end up blaming each other if your child suffers an arm injury.
The American Academy of Pediatrics' 2012 revised Policy Statement14 says "Young pitchers should avoid pitching on multiple teams with overlapping seasons," and calls for the enforcement of rest requirements across all teams.
If you do let your child play on more than one team at once, it may be up to you, as his parent [3], to keep track your child's pitch counts and days off and to insist that the coaches not exceed those overall limits.
The 2011 Little League pitching injury study emphasized the importance of explaining to "coaches, parents and players the high risk and limited reward of travel ball and showcases."
Again, the statistics are not encouraging: statistics from Safe Kids International suggest that nearly a third (30.4%) of youth baseball pitchers pitch with mutliple teams, and 13.2% pitched year round.
Poor pitching mechanics can put additional stress on a young arm and increase the risk of injury, experts say.
It will come as no surprise to anyone who watches youth and high school baseball with any regularity that pitchers in their teens have better throwing mechanics than younger pitchers.
A video analysis of youth pitchers reported in a 2009 article in the American Journal of Sports Medicine9 confirmed that adolescent pitchers (ages 14 to 18) performed better than youth pitchers (ages 9 to 13) on five simple measures of pitching mechanics (leading with the hips, hand-on-top position, arm in throwing position, closed-shoulder position, and stride foot toward home plate). The pitching motions of fully eight out of ten adolescent pitchers met 3 or more parameters compared with just two-thirds of the younger age group (although, unexpectedly, youth pitchers (86%) outperformed their older counterparts (66%) on the stride foot toward home plate measure).
The study suggests that the five measures of pitching mechanics studied may be developmental milestones for youth pitchers as they improve their mechanics over the years and learn to pitch, although it is unclear whether the development is a function of coaching and instruction [7] or whether athletes more easily perform them as neuromuscular function improves with age. [7]
Proper positioning of the throwing arm [7] during all phases of the pitching motion can reduce the number of injuries. According to Thomas J. Gill, M.D., an orthopedist at the Massachusetts General Hospital and Boston Red Sox team physician. "Pitcher's arm movements during different phases of the pitching motion, if performed incorrectly, can cause injury," he says.
Researchers identified four problem areas:
Players should follow a step-by-step approach to learning how to pitch:
Use of lighter balls may lessen the risk of overuse injury in pitchers between ages 9 and 12.
The American Academy of Pediatrics' 2012 Position Statement on Baseball and Softball14 includes a recommendation that a preseason conditioning program that includes strengthening the core, the rotator cuff and the shoulder-stabilizing muscles (scapular stabilizers) may help reduce throwing injuries.
Many baseball coaches also believe strength and conditioning is important, not just of the arm, but the legs as well.
For an article on shoulder stretching and conditioning exercises, click here [8].
The stories about youth baseball pitchers pitching in pain to the point of injury abound. A 2014 study16 found that a third of youth pitchers reported arm pain, with 25% reporting that they "often" or "always" had pain the day after they threw. An alarming 46% of the players surveyed reported at least once being encouraged to keep playing despite having arm pain.
"It's tough for kids to know the difference until they've been though it several times (maybe even into high school), " he says. "Coaches have a tough time knowing the difference because it's not their arm and they aren't feeling it. Part of what we need to teach the kids is to know their own bodies," Clemens says.
"As coaches we need to err on the side of caution. But I know that if kids only throw on the days they feel great, they'll only be doing it once or twice a week - and that's a "weekend warrior" strategy that's a surefire recipe for injury," Clemens says.
He recommends that kids throw 4 to 6 times a week (throw, not pitch) in order to build arm strength, which is what prevents a lot of injuries. To do this, they'll have stiffness they have to work through. Just as the only way for runners to work out the pain and stiffness from the previous day's run is to go lace up the shoes, Clemens says. "I've tried this excuse and it only makes the run later in the week worse!"
Pitchers may be unable to resist the temptation to overthrow, subjecting them to increased risk of injury (see #5 above).
Some experts [22], including Ron Wolforth of Texas Baseball Ranch and Pitching Central,10 recommend the use of radar guns, not out of an obsession with velocity but because of their value to measure pitcher fatigue [23] (see #1 above)(in other words, a drop off in velocity is a tell-tale sign that a pitcher is tired, regardless of competitive level, from youth baseball up to Major League Baseball).
Showcases (multi-day, high-level events in which athletes may play in multiple games in a short period of time) provide young players the opportunity to show off their skills to scouts at higher levels of baseball.
As USA Baseball notes,8 "Unfortunately, showcases often occur near the end of the player's season, when players are often fatigued and require rest and recovery. In other instances, players participate in a showcase after a prolonged period since the league ended and without adequate preparation for throwing hard again. It is without a doubt that young throwers will try to overthrow at these events in an effort to impress the scouts, which further increases the risk of serious arm injury."
The 2011 Little League pitching injury study reported that pitching in showcase events was associated with an increased risk of elbow and shoulder injury for those who also pitched in Little League Baseball and in high school pitchers.
The pitcher-catcher combination results in too many throws and may increase the risk of injury. Little League Baseball instituted a new rule for 2010 [14] banning any pitcher who delivers 41 or more pitches in a game from going behind the plate to play catcher for the remainder of the day.
The results of the 2010 ASMI study [4]5 appear to support such a ban. While it found that playing catcher appeared to double or triple a pitcher's risk of injury, the small number of injured players in the study prevented a finding that the risk was statistically significant. Nevertheless, the authors concluded that playing both pitcher and catcher in the same game or on the same day be "discouraged."
For its part, the National Athletic Trainers' Association 2011 position statement on overuse injuriess4 [1] advises "caution when combining pitching with other demanding throwing positions (e.g. pitch 1 day and catch the next day) to ensure adequate time for recovery."
As noted in the 2010 ASMI study,5 "the relationship between pitch types (particularly curveballs) and injuries in youth baseball pitchers is less clear [than between number of pitches thrown and injury risk] and more controversial."
The 2002 ASMI study2 found associations between breaking pitches and arm pain, but found, unexpectedly, a relationship between throwing sliders and increased risk of elbow pain and an association between throwing curveballs and increased risk of shoulder pain.
Three biomechanical studies, one published in 20087 and two in 2009 9,11 all found a curveball less stressful to the elbows of youth and high school pitchers than the fastball. The studies thus appear to pour cold water on earlier studies and the conventional wisdom that throwing curve balls at a young age leads to so-called "Little League elbow."
Glenn Fleisig, chairman of research at ASMI and co-author of one of the 2009 studies,9 told the New York Times12 in 2009 that he didn't "think throwing curveballs at any age is the factor that is going to lead to an injury."
Carl Nissen, the author of the other 2009 study,11 said in the sameTimes article that he could "comfortably stand up and say the curveball is not [part of the injury] problem."
Interviewed by the Times, however, Dr. James Andrews of ASMI, who had previously recommended against pitchers throwing curveballs before age 14, warned that the new findings "may do more harm than good" because he feared parents and coaches would interpret the findings improperly as a license to teach kids to throw too many curves or begin when they were too young.12
He also cautioned that the study9 he co-authored with Fleiseg, his longtime ASMI colleague, had limitations because it was conducted under laboratory, not game conditions and he continues to believe that, when young pitchers are tired, throwing curves could still be dangerous, citing the story of a 12-year-old on whom he operated the day of the interview who at age 12 had torn the ulnar collateral ligament in his elbow in two after throwing 30-something curveballs in a row, the last one snapping his elbow.
The 2010 ASMI study5 attempted to study the risk of serious injury from throwing curve balls before age 13 but, while it seems to show a slight increased risk associated with starting curve balls at a young age, the study had far too few participants to determine such an association. Thus, the true risk of serious injury from starting to throw curve balls at an early age is still unknown.
In its 2011 position statement on overuse injuries [1],4 the National Athletic Trainers' Association, largely comes down on Dr. Andrews's side of the debate. The NATA points out potential flaws in the two biomechanical studies: "It is important to note that the participants in these studies were healthy, with no history of arm injury, and in the case of the [2009] study, perhaps slightly older than the players who are generally the target of the recommendations against throwing breaking balls."
Thus the NATA recommends that parents and coaches restrict the use of breaking pitches in order to prevent pitching-related arm injuries. If an individual pitcher can throw breaking pitches on a limited basis and remain symptom free, the NATA says, then it may be allowed. If any throwing-related symptoms of overuse injury develop, however, the NATA says, throwing breaking pitches should be immediately terminated and medical attention sought.
More recently, a 2011 study [5] by researchers at the University of North Carolina and commissioned by Little League Baseball stated that, while the "relationship between age, type of pitch, and injury is complex, ... there was no clear evidence that throwing breaking pitches at an an early age was an injury risk factor."
The last word, to this point, on the subject of curve balls is contained in the American Academy of Pediatrics' 2012 Position Statement,14 While acknowledging the recent studies challenging the theory that the curveball and slider were stressful to the young elbow, the AAP continues to endorse the recommendation, based on studies that show increased injury among those who throw curve balls and sliders at early ages, that introduction of the curve ball be delayed until after age 14 or when pubertal development has advanced to the stage when the athlete has started to shave, and that sliders should be delayed until age 16. (Update: The AAP has since been joined in this recommendation by USA Baseball and MLB, who recommend in their Pitch Smart program that players younger than 14 avoid throwing pitches other than fastballs and changeups, and that older pitchers only begin using breaking pitches after developing a consistent fastball and changeup.
1. Lyman S, Fleisig GS, Waterbor JW, et al. Longitudinal study of elbow and shoulder pain in youth baseball pitchers. Med Sci Sports Exerc.2001;33(11):1803-1810.
2. Lyman S, Fleisig GS, Andrews JR, Osinski ED. Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers. Am J. Sports Med 2002;30(4):463-468.
3. Olsen SJ 2nd, Fleisig GS, Dun S, Loftice J, Andrews JR. Risk factors for shoulder and elbow injuries in adolescent baseball pitchers. Am. J Sports Med. 2006;34(6):905-912.
4. Valovich McLeod TC, Decoster LC, Loud KJ, Micheli LJ, Parker JT, SandreyMA, White C. National Athletic Trainers' Association Position Statement: Prevention of Pediatric Overuse Injuries. J Ath. Tr. 2011;46(2):206-220.
5. Fleisig G, Andrews J, Cutter G, Weber A, Loftice J, McMichael C, Hassel N, Lyman S. Risk of Serious Injury for Young Baseball Pitchers: A 10-Year Prospective Study. Am. J. Sports Med. 2010;20(10): 1-5.
6. Kaplan KM, Jobe FW, Morrey BF, Kaufman KR, Hurd WJ. Comparison of Shoulder Range of Motion, Strength, and Playing Time in Uninjured High School Baseball Pitchers Who Reside in Warm- and Cold-Weather Climates.Am.J Sports Med. 2011; 39(2): 320-328.
7. Dun S, et. al., A Biomechanical Comparison of Youth Baseball Pitches: Is the Curveball Potentially Harmful? Am.J. Sports Med. 2008;36(4):686-692.
8. ASMI Position Statement for Youth Baseball Pitchers, August 2009 [24].
9. Fortenbaugh D, Fleiseg G, Andrews J. Baseball Pitching Biomechanics in Relation to Injury Risk and Performance. Sports Health: A Multidisciplinary Approach 2009;1:314-320.
10. Wolforth, Ron, Observational Fatigue & New Guidelines [22] (accessed May 27, 2010)
11. Davis, J.T., et. al. The Effect of Pitching Biomechanics on the Upper Extremity in Youth and Adolescent Baseball Pitchers. Am. J. Sports Med. 2009;37(8):1484-1491.
12. Hyman, Mark, "StudiesShow That the Curveball Isn't Too Stressful for Young Arms [25]," NewYork Times (July 26, 2009).
13. Fazalare J, Magnussen R, Pedroza A, Kaeding C. Knowledge of and Compliance With Pitch Count Recommendations: A Survey of Youth Baseball Coaches. Sports Health: A Multidisciplinary Approach. published online February 6, 2012. DOI:10.1177/1941738111435632 (accessed February 7, 2012).
14. American Academy of Pediatrics Council on Sports Medicine and Fitness, Baseball and Softball Policy Statement (doi 10.1542/peds 2011-3593)(www.pediatrics.org/cgi/doi/10.1542/peds2011-3593 [26] (accessed February 27, 2012).
15. Hurd W, Jazayeri R, Mohr K, Limpisvasti O, El Attrache N, Kaufman K. Pitch Velocity Is A Predictor of Medial Elbow Distraction Forces in the Uninjured High-School Aged Baseball Pitcher. Sports Health: A Multidisciplinary Approach. 2012; DOI:10.1177/1941738112439695 (accessed March 22, 2012)(published online ahead of print).
16. Makhni E, Morrow Z, Luchetti T, Mishra-Kalyani P, Gualtieri A, Lee R, Ahmad C. Arm Pain in Youth Baseball Players: A Survey of Healthy Players. Am J Sports Med. 2014;20(10). DOI: 10.1177/03636546514555506 (published online Nov. 3, 2014).
Additional sources:Berler, Ron "Arm-Control Breakdown", New York Times (August 9, 2009) [27]
Krajnik, et. al. Shoulder Injuries in US High School Baseball and Softball Athletes, 2005-2008. Pediatrics 2010;125(3):497-501.
The Learning Curve: Little League Seeks to Address Concerns, Answer Questions about Curveballs and Overuse (Little League International 2011).
Berra L. "Force of Habit" [10]ESPN The Magazine, April 2, 2012 [10] (accessed March 30, 2012)
Guidelines for Youth and Adolescent Pitchers [11] (accessed October 2, 2015)
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[5] https://www.momsteam.com/node/3715
[6] https://www.momsteam.com/node/3305
[7] https://www.momsteam.com/node/2938
[8] https://www.momsteam.com/node/2988
[9] https://www.momsteam.com/node/3306
[10] http://espn.go.com/mlb/story/_/id/7712916/tommy-john-surgery-keeps-pitchers-game-address-underlying-biomechanical-flaw-espn-magazine
[11] http://m.mlb.com/pitchsmart/pitching-guidelines/
[12] https://www.momsteam.com/node/3030
[13] https://www.momsteam.com/node/815
[14] https://www.momsteam.com/node/816
[15] https://www.momsteam.com/node/2936
[16] https://www.momsteam.com/node/4414
[17] https://www.momsteam.com/node/4622
[18] https://www.momsteam.com/node/2606
[19] https://www.momsteam.com/node/3344
[20] https://www.momsteam.com/node/291
[21] https://www.momsteam.com/alpha/features/health_safety/physical_therapy.shtml
[22] http://www.webball.com/cms/page7199.cfm
[23] https://www.momsteam.com/node/3346
[24] http://www.asmi.org/asmiweb/position_statement.htm
[25] http://www.nytimes.com/2009/07/26/sports/baseball/26score.html?scp=1&sq=Mark Hyman curveball&st=cse
[26] http://www.pediatrics.org/cgi/doi/10.1542/peds2011-3593
[27] http://www.nytimes.com/2009/08/09/magazine/09littleleague-t.html?_r=1&scp=1&sq=Ron Berler Arms-Control Breakdown&st=cse
[28] https://www.momsteam.com/sports/baseball/safety/preventing-baseball-injuries
[29] https://www.momsteam.com/sports/baseball/safety/2014-little-league-baseball-pitch-count-limits-and-mandatory-rest-periods
[30] https://www.momsteam.com/sports/daily-pitch-limits-usa-baseball-little-league-rules-different
[31] https://www.momsteam.com/sports/exercises-assess-strength-pitching-shoulder
[32] https://www.momsteam.com/health-safety/stretching-exercises-maintain-shoulder-flexibility-reduce-injury-risk
[33] https://www.momsteam.com/health-safety/general-safety/injury-prevention/dynamic-stretching-recommended-as-part-sports-warm-up
[34] https://www.momsteam.com/sports/youth-baseball-pitching-teaching-proper-mechanics-critical
[35] https://www.momsteam.com/overuse-blamed-for-youth-pitching-injuries-but-sliders-and-curveballs-still risk
[36] https://www.momsteam.com/breaking-pitches/preventing-pitching-injuries-curve-ball-debate-continues
[37] https://www.momsteam.com/sports/too-many-curve-balls-in-youth-baseball
[38] https://www.momsteam.com/sports/preventing-pitching-injuries-up-to-parents-where-playing-on-multiple-teams