More adolescents are participating in Little League baseball in the United States than ever before according to a 2016 article in the American Journal of Sports Medicine. With this growing number of youth in baseball there has been an epidemic of upper extremity injuries in young throwers. Recent research has demonstrated that 30% to 40% of 7- to 18-year-old baseball players experience elbow and shoulder pain during the season. This is of great importance because up to 46% of injured adolescents report being encouraged to keep playing despite having arm pain.
Increased year-long play and specialization have been identified as major contributors to the high number of young throwing athletes coming down with overuse injuries. A common injury to a young athlete is the dreaded full-thickness ulnar collateral ligament (UCL) rupture. For some of you older athletes reading this article you will remember hearing about this injury and the resultant experimental surgical procedure to repair this ligament as the “Tommy John” surgery. Los Angeles Dodgers team orthopedic surgeon, Dr. Frank Jobe, performed this surgery on star pitcher Tommy John, in 1974. This surgical procedure had never been performed and this ligament graft on a high level athlete had a chance of success of the operation to be 1 in 100. Tommy John was able to return to the starting line-up and had great success a year later. Now the surgical treatment for UCL ruptures had a success rate of up to 85% - 92% by 2009. More recent research in New York State demonstrated that the incidence of UCL reconstruction in patients 17-20 years old is rising significantly, greater than for any other age group.
Early Detection
Early detection of overuse injuries may be able to prevent further progression. Because throwers are told frequently to keep playing despite painful symptoms, the importance of early and complete evaluation of elbow pain in the young thrower is paramount. The evaluation of elbow and/or shoulder pain in young athletes should include the following:
1. The level of play,
2. Extent of the participation (i.e. year-long play)
3. A thorough intake history and physical exam (performed by your Medical Doctor (MD) or Doctor of Physical Therapy (DPT))
4. collection of appropriate patient-reported outcomes
5. Imaging as a last option in the assessment of the injured youth.
Youth Sports Specialization
It comes with no surprise that sports specialization is a key factor in the rise of shoulder and elbow injuries in youth. Some factors contributing to the throwing injury epidemic include an intrinsic desire for success, participation in multiple leagues, and external pressure from parents and coaches. Young athletes who played a single sport for more than 9 months in a year and who had higher levels of weekly participation had a 36% increase risk of severe overuse injuries compared to healthy controls. In a recent article in the Journal of Orthopaedic & Sports Physical Therapy (JOSPT, 2018) Doctor’s from Columbia University Medical Center stated, Currently, half of high school baseball players and more than 25% of players, coaches, and media members answered that they believe that UCL reconstruction, also known as Tommy John surgery, was required to enhance the strength of healthy players’ elbows. This is outrageous and flawed thinking. Physicians, physical therapists and athletic trainers must eradicate these myths and counsel parents, players, and coaches regarding the risks of youth sports specialization.
Today many professional athletes and coaches are speaking out about sports specialization. Football legend and Ohio State football coach Urban Meyer discusses why his recruiting boards include multi-sport athletes as they are trying to find naturally talented athletes, and he specifically states that he doesn’t want athletes that specialize in football. Houston Texans defensive end J.J. Watt frequently speaks out against sports specialization. He states that kids will be better athletes by playing multiple sports. Let’s look at some statistics to back up this debate. Thirty of the 32 first round draft picks in last years (2017) NFL draft were multisport athletes in high school.
Benefits of multi-sport athletes
1. The youth athlete learns to develop different skills when playing different sports. There is great carryover of agility drills performed in football that can enhance quickness and speed for the baseball player. Or the ball handling skills of a basketball player can enhance playing baseball.
2. There are minimal burnout issues when a high school kid moves from football to basketball and then to baseball in a span of 10 months.
3. Lower risk of overuse injury when participating in multiple sports.
4. Confidence builds with skilled coaching in each discipline and this translates to improved overall skill levels and most importantly can enhance self-esteem.
Great Athletes that were multisport athletes
Jackie Robinson was one of the best multisport athletes ever to play Major League Baseball (MLB). He lettered in baseball, football, basketball and track in high school, junior college and at UCLA. Robinson was the nation’s leading punt returner in average yards in 1939 and ’40 for the Bruins, and he lead UCLA in passing, rushing, scoring and punt returns in ’40, his senior year.
Jim Thorpe was one of the greatest athletes ever to be put on Earth. He was a multiple Olympic gold medalist as well as a professional baseball player. He played on four big league teams from 1913-19 while embarking on a long pro football career that saw him reach the NFL in 1920 and played eight seasons.
John Elway – Before he was a nine-time Pro Bowler was selected by the Yankees in the second round of the 1981 MLB Draft. Elway played just one season in the Minors. He hit .318/.432/.896 with 12 extra base hits and eight outfield assists in 42 games.
There are many more examples of great athletes that played in the NFL and MLB such as Tim Tebow, Deon Sanders and Bo Jackson and all of these athletes actively promote multisport participation.
Prevention
Addressing the increase of serious elbow injuries must begin with identifying causative factors and establishing evidence-based preventative measures. Research has not yet been able to point a finger at any single causative factor of elbow shoulder overuse injuries in throwers. Despite these efforts, the number of overuse injuries continue to increase. Strict evidence-based guidelines must be instituted to address this trend. Most importantly, enforcement of pitch counts for young players, the number of leagues players participate in, and the number of months of participation per year in a single sport is required.
Total body conditioning, including hip, back, and lower extremity strengthening, may be able to optimize a player’s biomechanics to reduce strain on the arm. Multisport participation does just that. Most importantly, playing in a variety of sports to increase athletic dexterity, rather than engaging in early sports specialization, may protect these players while enhancing athleticism. Lastly, if a youth athlete is in rehabilitation stringent adherence to throwing protocols must be met, including taking time off from throwing if indicated.
Imaging
Imaging should be used judiciously due to these highly sensitive devices such as the MRI. A great deal of “False positives” or incidental abnormalities can be interpreted and treated inappropriately. One study reported that more than 80% of young baseball players demonstrated elbow x-ray abnormalities at preseason evaluation, the majority of whom were asymptomatic. Another study demonstrated that abnormalities were found in routine preseason MRI examinations of 35% to 48% of young baseball players, with abnormalities more often found with those athletes that were in year-round leagues and with private coaching. The take home message of imaging in almost every part of the body when treating musculoskeletal pain is, “If you image it, it will show abnormalities.” So don’t rush out and ask your doctor for imaging unless all conservative treatments have failed and pain is still present. Remember, sometimes a long rest period or changing up the game is the best medicine.
Treatment Options
Telling a competitive athlete and his parents that “resting the arm” is indicated is always a hard sell. However, conservative treatment of youth throwing athletes is very successful when full adherence to a program has been implemented. Doctors Padaki and Ahmad from Columbia University state that nonoperative treatment must be taken seriously in young athletes, as increasing evidence suggests its potential for success. Partial ligament damage is rare in young athletes, and partial UCL tears can be treated successfully with physical therapy even in the MLB players.
Final Note: Do softball pitchers get the same injuries as the overhead-throwing athlete? Short and simple answer is, No. The biomechanics of the windmill underhand softball pitch lends itself to a very efficient throwing motion. There are very few overuse throwing injuries reported and treated in softball pitchers.
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