Tales from the Slot - Washington District 9 · • Intelligent •Durable. To be discussed •Pitching kinematics •Statistics •Injuries of the shoulder and elbow •Prevention

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



Head Movement



Balance And Body

Movement



Hand Separation



Elbow Alignment

Correct

Inverted W = Elbow injury!!



Upper Body And

Shoulder Position



Forward Movement

After Knee Lift And

"Pushing" Off The

Mound



Landing



Follow Through And

Finish



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

•

Documents

Tales from the Slot - Washington District 9 · • Intelligent •Durable. To be discussed •Pitching kinematics •Statistics •Injuries of the shoulder and elbow •Prevention