1

Overuse Injuries in

Adolescent Baseball Pitchers

Glenn S. Fleisig, Ph.D.

Epidemic of Adolescent Pitching Injuries?

2

Epidemic of Adolescent Pitching Injuries?

• National Database

• Professional Database

• ASMI Database

0

10

20

30

40

50

60

70

80

90

100

1974 1984 1994 2004 2014

UCL Surgeries in Professional Baseball

www.BaseballHeatMaps.com

3

Major League (n=382)

Minor League (n=2324)

Conte et al, 2015

UCLr(15%)

No UCL reconstruction (85%)

UCLr

(25%)

No UCLr

(75%)

Prevalence of UCL Surgery in Pro Pitchers

0

20

40

60

80

100

120

140

160

180

200

1994 1996 1998 2000 2002

UCL Surgeries on Pitchers at ASMOC

All

Adolescent

4

11%

18% 18% 18%21%

29%28%

32% 31%

38% 38%

44%

40%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

UCL Surgeries on Pitchers at ASMOC

Adolescent

Adult

0

500

1000

1500

2000

2500

1995-99 2000-04

10% (227)2.5% (43)

Shoulder Surgeries by Dr. Andrews

5

• Repetition

• Self-inflicted

• Overuse

Surgeries from Pitching

Rick Factors for Pain

Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers

Lyman et al, Am J Sports Med 2002

• Spring 1999

• 476 youth pitchers (age 9-14 yrs)

• Pain questionnaire the day after every game

• Pitch counts from each game

6

Rick Factors for Pain

0

1

2

1-24 25-49 50-74 75-99 100+

# of pitches in game

Elbow

Shoulder

Rick Factors for Pain

0

1

2

3

4

1-200 201-400 401-600 601-800 800+

# of game pitches so far in season

Elbow

Shoulder

7

Rick Factors

Injury?Risk factors Pain

• 1999 - 2008

• Alabama

• 481 youth pitchers

• 1999

• Alabama

• 481 youth pitchers

Fleisig GS, et al. 2011.

ASMI 10-Year Study

0

50

100

150

200

250

300

350

400

450

500

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Played but not Pitched

Pitched

8

About 5% of youth pitchers will have a

serious arm injury by age 20.

Injuries = 24 / 481 = 5%

ASMI 10-Year Study

ASMI 10-Year Study

More than 100 innings/yr more than triples

the risk of arm injury.

Study showed 3.5 times risk (p = 0.05)

9

USA Baseball study

• Mueller, et al. at UNC

• Funded by Yawkey Foundation

• 5-year study (2006-2010)

– Little Leaguers (n=410) for 5 years

– High school (n=293) for 4 years

– NCAA pitchers (n=629) for 3 years

USA Baseball study

• High School Pitchers

– Overlapping leagues Elbow pain, Shoulder pain

– Showcase Shoulder pain, Elbow injury

– Pitching with tiredness Shoulder injury

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Amount of Pitching

• Olsen et al, 2006

– Adolescent pitchers (14-20 yrs)

– 66 elbow surgery

– 29 shoulder surgery

– 45 healthy

Amount of Pitching

• > 80 pitches/game 4 times

• > 8 months/year 5 times

• Pitched fatigued 36 times

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Warm-Weather vs. Cold-Weather

Warm-Weather Year-Round Pitching Injuries?

Erickson et al., 2014

Warm-Weather vs. Cold-Weather

12

Warm-Weather vs. Cold-Weather

Amount of Pitching

• Too much pitching Injury

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• Excessive pitching is not natural

• Throwing is natural

– Avoid too much competitive pitching

– Avoid too little throwing and physical activity

Amount of Pitching

1900s

Amount of activity

Nu

mb

er o

f kid

s

14

1950’s

Nu

mb

er o

f kid

s

Amount of activity

2000’s

Pitching Biomechanics

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Biomechanics Data Collection

Biomechanics Data Collection

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ASMI Throwing Tests: 1989-present

1993 Cy Young

1986, 1987, 1991, 1997,

1998, 2001, 2004 Cy Young

2002 Cy Young2007 Cy Young

2008 Cy Young 2009 Cy Young2003, 2010 Cy Young

200 Elite PitchersThrew >85mph during testing

Healthy for 1 year

2000+ Pitchers

2006 Cy Young

Varus Torque = 100 N-m

UCL Injury Mechanism

17

UCL provides ~ 55% of varus torque

UCL Torque = 55% of 100 Nm = 55 Nm

UCL strength = 32 Nm

Varus Torque = 100 N-m

UCL Injury Mechanism

Pitching Mechanics

• Fleisig GS. UAB dissertation 1994.

• Fleisig GS et al. Am J Sports Med. 1995.

• Fleisig GS, et al. J Biomech. 1999.

• Matsuo T et al. J Appl Biomech. 2006.

• Escamilla RF et al. Am J Sports Med. 2007.

• Dun S, et al. Am J Sports Med. 2008.

• Chu Y, et al. J Appl Biomech. 2009.

• Fleisig G, et al. Sports Biomech. 2009.

• Fortenbaugh D, et al. Sports Health. 2009.

• Robb AJ, et al. Am J Sports Med. 2010.

• Urbin MA, et al. Am J Sports Med. 2013.

• Fleisig GS, et al. Sports Biomech. 2013.

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Pitching Mechanics

• Improper Mechanics

Decreased ball velocity

Increased Elbow & Shoulder force & torque

Curveballs are

dangerous for kids?

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“Curveballs are Dangerous(?)”

• Doctors

• Trainers

• Coaches

• ASMI

Curveball Biomechanics

• Fleisig GS, et al. Am J Sports Med (2006)

• Dun S, et al. Am J Sports Med (2008)

• Nissen CW, et al. Am J Sports Med (2009)

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Elbow Varus Torque

Age Range Fastball Curveball

Dun et al. 10 to 15 yrs 35 Nm* 32 Nm*

Nissen et al. 14 to 18 yrs 60 Nm* 54 Nm*

Fleisig et al. 18 to 22 yrs 82 Nm 79 Nm

* Significant difference between fastball and curveball torques

• Age when a pitcher started throwing curveballs

did not affect injury risk

– Olsen et al, 2006

– Fleisig et al, 2011

– Register-Mihalik, 2012

Curveballs

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Performance after UCLr

Major League Minor League Amateur

Sample size 24 88 144

Return to same level 79% 76% 89%

Time to full competition 12 months

• Cain et al, 2010

• Osbahr et al, 2014

Return to Play – High School Pitchers

UCL Surgery

(n=218)

Shoulder “SLAP”

Repair (n=69)

Returned to Play 92% 77%

Played College or Higher 38% 26%

Played Professional 10% 4%

• Axe et al, unpublished

22

Conclusion

• High rate of pitching injuries

• Injuries from repetition

• Fatigue Injury

• Too many pitches Injury

Pitch Safety Recommendations

• ASMI

• USA Baseball

• Pitch Smart

Thank You!