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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
10
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
11
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
13
• 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
15
Biomechanics Data Collection
Biomechanics Data Collection
16
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.
18
Pitching Mechanics
• Improper Mechanics
Decreased ball velocity
Increased Elbow & Shoulder force & torque
Curveballs are
dangerous for kids?
19
“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)
20
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
21
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!