Post on 29-Aug-2020
Tales from the Slot:
Are we letting our kids throw their
arms out?
Vincent M Santoro, MD425.990.8300
ShoulderWorks.com
Eastside Orthopedics and Sports Medicine
"For the parents of Little Leaguers, a baseball game is
simply a nervous breakdown divided into innings." -Sportswriter Earl Wilson
Speed is intoxicating
…but “speed” kills…
• Joel Zumaya: BOTH
shoulder and elbow
surgery
• On and off DL over last
5 years
• Now retired because of
elbow blow out
• 104.8mph
The DL is lonely place for pitchers…and
costly
P
I
T
C
H
E
R
S
Injuries to pitchers are increasing
• Yet the desire for speed
continues…
• Kids think the way to
the Bigs is to throw
harder than the next
guy
• But, at what risk?
So can we teach kids to throw hard
without injury?
Can we build the perfect pitcher?
• Hard throwing
• Competitive
• Intelligent
•Durable
To be discussed
•Pitching kinematics
•Statistics
•Injuries of the shoulder
and elbow
•Prevention
•Review current LLB
guidelines for pitchers
My Bones
• 23 years Orthopedic surgeon
• Univ of CT, WA and Berne
• Fellowships in Trauma and Shoulder/Knee
• Practice specializes in Surgery and Care for Shoulder, Knee and Sports injuries
• Co-Founder ShoulderWorks, a specialty clinic for shoulder problems and problem shoulders
• Team Doc for 20 years for HS and Club sports in CT, WA: football,soccer
• Team Doc for WPSL Issaquah Pro womens Soccer, Seattle Majestics
Ex-jock with a bum shoulder
•Max speed: 86mph at 16•Pitched from 1963-77: Little League, Sandy Koufax, Babe Ruth, Connie Mack, HS, one year college
•QUIT baseball age 19 when
my FB ~ 82mph; and Atomic Balm and lifting weights no longer helped!
•From the era that had no concept about PT!
Pitching
• Complex coordination
of numerous muscle
contractions
• Synchronicity of upper
and lower body to
accelerate a ball from
0 to 105mph in < 0.2sec
Complexity
• Heightened during a
game due to the need
for velocity, command
AND location
• Situational with a huge
mental component
which adds additional
stress!
Throwing a baseball
• is difficult for a child
until his hand grows!
• He needs to learn HOW
to throw first before he
can throw hard
3
Pitching is violent!
MASSIVE TORQUE GENERATION
@ Shoulder and Elbow
Angulatory velocity of the shoulder = 7000°/sec
= 20 arm revs/sec!
Stress is profound!
• Force generated at the
shoulder and elbow
during a during high
speed pitch EXCEEDS
the ultimate failure load
as seen in the lab !!
• And joint forces
increase as an athlete
matures thus increasing
injury potential
Literally throwing your arm off
• Making the shoulder
and elbow susceptible
to devastating injury
• Strassberg, Moyer,
Zumaya, Carpenter,
Jiminez..
Pitching Motion
Time from footstrike to
ball release is 0.145 sec
Ball acceleration from 4-
85+ mph
Foot strike to ball release: 0.145 sec
Fluid mechanics is protective
Fundamental pitching mechanics
• Need to be learned at an early age so that they
remain constant thru the developing years
Key factors
• Include
1. Arm flexibility/SLOT
2. Arm strength
3. Hip/spine rotation
4. Stride length
5. Lower leg strength
Gotta “cock the gun”
103 mph
105mph
THE SLOT
Size matters…
60mph
188mph
THE SLOT
LONGER LEVER ARM INCREASES
MECHANICAL ADVANTAGEINCREASING BALL SIZE DETRIMENTAL
RIGHT LEFT
Kinematics: Stride
Increased stride = increased velocity
135°135°
ACCELERATION :
shoulder SLOT
position to MAX IR,
elbow flex to extend
DECELERATION: RC
tensile force
dissipating KE after
ball delivery, max
load to elbow
FOLLOW THRU: balance
Injury most common in Cocking and
Deceleration phases
Common Pitching Flaws
• Pitching Fault - Poor
Lift Leg Action
IncorrectCorrect
Common Pitching Flaws
• Pitching Fault - Poor
Head Movement
Common Pitching Flaws
• Pitching Fault - Poor
Balance And Body
Movement
Common Pitching Flaws
• Pitching Fault - Poor
Hand Separation
Common Pitching Flaws
• Pitching Fault - Poor
Elbow Alignment
Correct
Inverted W = Elbow injury!!
Common Pitching Flaws
• Pitching Fault - Poor
Upper Body And
Shoulder Position
Common Pitching Flaws
• Pitching Fault - Poor
Forward Movement
After Knee Lift And
"Pushing" Off The
Mound
Common Pitching Flaws
• Pitching Fault - Poor
Landing
Common Pitching Flaws
• Pitching Fault - Poor
Follow Through And
Finish
Common Pitching Flaws
• Pitching Fault - Poor
Fielding Position After
Pitch Is Made
Injury is a continuum
• Overuse
• Muscle fatigue
• Transient soreness
• Macrotrauma
• Pain
• Tears
Overuse leads to fatigue
• Fatigue leads to Muscle
weakness producing a
loss of dynamic support
for the joint, thus
rendering increased
load on the vulnerable
ulnar collateral
ligament of the elbow
and the cartilage and
rotator cuff in the
shoulder.
• That translates into
increased susceptibility
to tear!
At risk
• Shoulder—rotator cuff
and labrum
• Elbow– ulnar collateral
ligament
U
N
S
T
A
B
L
E
S
T
A
B
L
E
These are ALL stress related injuries
• Any child with
complaints of lingering
pain that does NOT
resolve with enforced
rest REQUIRES an
evaluation by an
Orthopedist or other
HCP FAMILIAR with
overuse injuries
These are ALL stress related injuries
• Workup consists of
• An accurate history of the onset of pain, the circumstances, prior history, player/parent/coach perspective
• Diagnostic imaging with Xray and MRI when needed
Shoulder
• Cocking puts shoulder
at risk due to rotational
stress and compressive
loads in the joint
• Deceleration puts
shoulder at risk due to
eccentric load on cuff
and labrum
Shoulder injuries
• Range from general
fatigue and stiffness to
Little Leaguer’s
shoulder (stress
fracture of the growth
plate) in the under 12
year old to full tears of
the rotator cuff and
labrum in throwers
from 14 years of age!!
Elbow
• Cocking loads the elbow
in valgus
• Deceleration puts the
elbow at risk 2°torque
Elbow injuries
• Range from fatigue to
Little Leaguer’s elbow
(stress fracture of the
growth plate) to full
blown ulnar collateral
ligament blowouts!
POP
Most injuries can be treated
nonoperatively• Early recognition can
lead to resolution!
• RICE
• Active rest, ie, NO
throwing
• PT: Sleeper stretches
and Rotator cuff
exercises!
Arthroscopy
Tommy John
• Became synonymous
with the UCL surgery
• Significant increase in
UCL tears in HS: 7x
increase in surgeries!!
• Kids now asking for the
operation
prophylactically
Facts
• 12M play baseball: 25%
pitch
• 2.6M LLB
• Overuse injuries
account for 50%
• >60% injuries occur
during practice!
Risk Factors
• 2001 survey of Little League pitchers,
• 26% experienced elbow pain during the season and
• 32% had an episode of shoulder pain.
• Arm fatigue during the game was a risk factor for pain in both the shoulder and elbow.
• Throwing more than 75 pitches in the game was a shoulder-specific risk factor;
• pitching on an additional team and weight lifting during the season were risk factors for elbow pain.
Risk factors
• 2006 study that
compared injured
adolescent pitchers
with uninjured controls.
1. Pitching in more than 8
months of the year,
2. throwing more than 80
pitches in a game, and
3. pitching with fatigue
• increased the risk of a
shoulder or elbow
injury more than 3-
fold.
• What are the signs of a BAD pitching Coach?
1. No experience in the top levels of the game.
2. No certified education in the world of pitching and athletic training.
3. A poor understanding of Physics Driven Pitching Mechanics.
4. A poor understanding of the physiology and psychology of his pitchers.
5. Over throwing his staff of pitchers.
6. Discouraging his pitchers from using a strength and conditioning program.
How A BAD Pitching Coach Can Ruin A GOOD Pitcher
by Brent Pourciau · January 18, 2009
7.Forcing his pitchers to throw more breaking
balls than fastballs.
8.Using Long Distance running to build
endurance in his pitchers.
9.Excessive amounts of long toss.
10.A poor warm-up and dynamic stretching
routine.
11.Not educating his pitchers on proper
athletic nutrition and rehabilitation.
12.Not educating his pitchers on the mental
game.
13.Uses a lot of poor conventional wisdom to
coach his pitchers.
Poor mechanics
•Puts undo stress on the
arm
•The inverted W sign is a
sure give away for injury
problems
Injury =Overuse + Poor mechanics
• 1.Speed of movement...which means is the
pitcher explosive or slow and controlled? Is his
tempo slow or fast? Is he like a sprinter getting
out of the starting blocks?
• 2.Does the pitcher look natural or "over-
coached?" Over-coaching appears as slow,
robotic and sometimes stiff.
• 3.Does the pitcher move from a bent leg to get
lower leading with his front hip and does he
land on a flexed leg in a straight line toward the
plate?
• 4.Is the front foot too closed off or angled too
much away from home plate? ( I am seeing this
a lot on young pitchers) For a RH pitcher his foot
is pointed to the third base side of the plate
instead being just slightly angled
•
Injury =Overuse + Poor mechanics
• • 5.Does the pitcher move sideways long enough
so that he completes his back leg drive before
he lands? Does his back leg get to near full
extension just before landing or is it still bent
just before landing?
• 6.Is his stride length nearing 100% of his height?
Short stride kills velocity and add stress to the
arm
• 7.Is his head positioned between his two feet?
(nose over bellybutton) upon landing?
• 8.At ball release is his support foot in contact
with the ground and is his head and chest
positioned out over his landing knee?
• 9.Does his entire support foot (heel included)
stay in contact with the ground and rubber as
long as possible so the weight shifts
• to the inside of the entire support foot while the foot drags down the mound surface?
• 10.Does he land with his weight on the middle to inside of his landing foot or is he falling off to one side or the other? Is he front knee positioned over his ankle? This is his foundation for transferring all the forces you want to get to the ball. If this is weak velocity and control is reduced and stress goes to the arm.
• 11.Does he take the ball out of the glove with fingers on top and thumb underneath swinging the hand down, back and up into the cocked position as late as possible? (or is he lifting the ball up using his elbows?) Does his throwing arm get back into a natural but fully extended position?
• 12.Does he break his hands late...after his lead foot is down and his head and front hip have started to move away from the rubber?
• 13.Does he brace-up his ankle and knee and hip so that upon landing his hip acts as the axis of rotation for his upper body?
• .
•
• • 14.Does he have good upright posture moving from the back leg to the front leg?
• 15.Has he removed all slow movement, hesitation and lateral (side-to-side) movement from his delivery including bending forward, leaning backwards or swinging the leg out and around?
• 16.At ball release is the pitcher's head and chest positioned in line with our better yet out over his landing knee. (if his head is behind his landing knee this indicates he is not creating enough forward momentum)
• 17.Does the pitcher finish with his trunk powerfully flexed forward to a flat back position? Other things to consider. Do the hands work together and sync up with the body. Thus why I like the hands moving up with the leg out of the wind-up and the hands positioned high on the chest to move down out of the stretch. Stationary hands do not allow good rhythm or timing. Get the hands moving.
ASMI Injury Prevention in Youth
Pitchers• 1.Watch and respond to signs of fatigue. If a
youth pitcher complains of fatigue or looks fatigued, let him rest from pitching and other throwing.
• 2.No overhead throwing of any kind for at least 2-3 months per year (4 months is preferred). No competitive baseball pitching for at least 4 months per year.
• 3.Do not pitch more than 100 innings in games in any calendar year.
• 4.Follow limits for pitch counts and days rest. (Example limits are shown in the table below.)
• 5.Avoid pitching on multiple teams with overlapping seasons.
• 6.Learn good throwing mechanics as soon as possible. The first steps should be to learn, in order: 1) basic throwing, 2) fastball pitching, 3) change-up pitching.
• 7.Avoid using radar guns.
• 8.A pitcher should not also be a catcher for his team. The pitcher-catcher combination results in many throws and may increase the risk of injury.
• 9.If a pitcher complains of pain in his elbow or shoulder, get an evaluation from a sports medicine physician.
• 10.Inspire youth pitchers to have fun playing baseball and other sports. Participation and enjoyment of various physical activities will increase the youth’s athleticism and interest in sports.
Prevention is critical…
awareness is key
Some would argue that
Being bigger and stronger
should make you more
durable!
Therefore, select BIG
KIDS to be pitchers!
• You can increase
muscle mass
But you can’t increase
the durability of
tendon and ligament
structure…
Risk Factors for injury
•OVERUSE/Poor Mechanics1.Arm fatigue
2.High pitch counts
3.Too little rest
4.Throwing too hard
5.Throwing breaking balls
6.Overparticipation
Cumulative risk of injury over 10 years = 5%
Arm fatigue
• Correlate strongly with injury
• 1/3 of pitchers 9-19 will c/o pain in their career and almost ALL will have arm fatigue at some point
• 36x likelihood of need for surgery OR retirement in pitchers who threw with arm fatigue or pain
Overthrowing
1. Some kids are throwing as many innings and pitches in a 12 month season as MLB pitchers
2. Too many throws cause injury!!
3. 50% reduction in arm injuries in leagues implementing pitch counts
Some would argue that
• Throwing more makes the arm stronger to protect against the torque
• Year-round throwing is acceptable because it facilitates endurance, adaptation, and accommodation to the movement. However, year-round pitching is not acceptable because it exacerbates arm stress–related wear and tear, no matter how efficient the pitcher's delivery
Lack of rest
• Resting the throwing arm is the primary tool for combating overuse and fatigue.
• Rest allows muscles to return to a state of readiness after the onset of fatigue by replenishing proper chemical levels for muscle contraction, such as calcium ions and energy stores, and for minor injuries to heal
Speed kills!
Desire for increased speed
can be detrimental in the
developing adolescent
leading to arm fatigue---
>85 mph correlates with
arm injuries (9-19)
•
Mixed messages
•Studies support that too early an introduction of breaking balls will have a deleterious effect
•One study showed curveballs increased the risk of injury at the shoulder while sliders increased at the elbow
• Others clearly show increased elbow problems with the curve
• Other studies say no effect?????????
2011 study University of North Carolina
commissioned by LLB showed• throwing curveballs is not the primary cause of arm injuries in Little League pitchers • injuries are principally the result of overuse:
1. throwing too many pitches/ innings ,2. playing on more than one team at a time, and3. pitchers throwing before they are fully recovered from a previous injury
• But even that study shows that curveballs increase the injury risk, if only slightly, and throwing sliders is second only to previous injury in increasing injury risk.
Average starter in the MLB
• Throws every 4-5 days
• Max ~100 pitches per
game
• 200 innings per year
• Throws only from April
to Sept
• 6 months OFF
Tremendous torque!
Overparticipation
• Year round ball
correlates with injury
• Little League, HS and
AAU …
• More than one team
per season
• OVERUSE!!!!!!!!!!
Complaints
• May be vague or very
focal
1. Arm feels tired
2. Stiff or tight
3. Can’t loosen up
4. Arm feels dead
5. Can’t bring it
6. It hurts!!
• YOU should look for the
following
1. Struggling
2. Loss of command
3. Loss of location
4. Loss of velocity
5. Changes in mechanics
Andrews study: Surgery Likelihood
RESULTS
•End of study: ONLY 2.2% still pitching
1.>100 innings per year, 3.5x risk
2.>8 months p.y., 500% inc risk
3.>80 pitches per game, 400% inc
4.Fastball>85mph, 250% inc
• 10 year study, 476 pitchers, 9-14 yo
Recommendations
Master in this order
1.CONTROL,
2.COMMAND,
3.VELOCITY,
4.BALL MOVEMENT
Maximum Pitch Counts
AGE•7-8
•9-10
•11-12
•13-16
•17-18
Source: Little League Baseball
• 50
• 75
• 85
• 95
• 105
PITCHES/GAME
Recovery
AGE
•7-14(sk.immature)
•15-18(mature)
Source: Little League Baseball
4 3 2 1
66 51-65 36-50 21-35
76 61-75 46-60 31-45
DAYS
Recommendations for pitchers
• Once removed from a
game, NO return to
field
• NO pitching and
catching same season
• NO pitching for more
than one team per
season
•Beware of end of season
Showcases: tired arms
prone to injury
Recommendations for pitchers
• Active Rest: NO overhead sports for at least 3 months per year
• PLAY MULTIPLE SPORTS
Guidelines for injury prevention:
strengthen the rotator cuff!
• Fatigue leads to injury!
• MRI studies have shown “damage” signal in the rotator cuff after a single pitching session!
• A pivotal study showed a strong correlation with weakness in RC strength and the chance of surgery !
• Research shows a well functioning ,strong RC will prevent injury!
• TOUGHEN YOUR CUFF!
Throwers TEN
Ballistic Six Exercise Program
• 6 Exercises:
• 1) Elastic External Rotation
• 2) Elastic 90o/90o External Rotation
• 3) Overhead Soccer Throw
• 4) 90/90 External Rotation Side Throw
• 5) Deceleration Baseball Throw
• 6) Baseball Throw
TuffCuff
TUFFCUFF.com
Year Round Conditioning
•Teach them how to care for
their bodies:
•Nutrition
•Fitness
•Flexibility
•Conditioning
•Strength
•Sound shoulder mechanics
•Good for ALL sports
Weight training
•Light weight, high rep
•No power weight
training prior to age
14!
•NO PEDs!!!
REMEMBER
THE #1 CAUSE OF
SHOULDER and ELBOW
INJURIES IS DIRECTLY
RELATED TO THE #
INNINGS/PITCHES YOU
LET THEM THROW!
Don’t ignore complaints:
Arm fatigue is the #1 complaint of those who eventually retire OR undergo surgery
Don’t ignore the signs:
Loss of control, command and velocity
Coaches, you must..
Master the Basics
Teach them:
1.Throw Correctly
2.Analyze change
3.Recognize Injuries
When They Occur
4.Be proactive
ARM approach
•Adherence to pitch count
•Rehabilitation exercises (strengthening and stretching) … Rest (3 months of rest per year)
•Mechanics (utilizing proper pitching mechanics)
BE THEIR ADVOCATE !
BOTTOM LINE
Ask your pitchers how they feel before, during and
after games! Don’t let them “pitch through” their
problems especially if they are laboring!!
Can we build the perfect pitcher?
• Probably not!
• But we can at
least try to
keep them out
of my office!
THANK YOU !!
VINCENT M SANTORO, MD
425.990.8300
www.ShoulderWorks.com
www.vinsantoro.com
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