Prevention of Overuse Injuries in the Adolescent Athlete
By Scott N. Stubbs, M.D.
The atmosphere surrounding our youth as it pertains to sports and sporting events has changed in the past several decades. The times of carefree participation and playing ‘for the love of the game’ are, at times, a thing of the past. The enjoyment of sports and healthy competition are indeed alive and well, but the pressure and demands that are being placed on our skeletally and emotionally immature adolescent children can approach disastrous levels. We have seen increasing numbers of throwing related injuries in recent years compared to the past. Clearly, this does not represent a diminution in talent on either the part of the athletes or the coaches. Rather, it represents pure and simple overuse and excessive demand.
Biomechanics of Throwing and Overuse
Overhead throwing sports—particularly baseball—require increased external rotation at the shoulder joint. The adaptive changes that must occur to achieve increased external rotation take place during the childhood and adolescent years. It is for this reason baseball and other overhead sports are considered "developmental sports". It has been repeatedly shown that bony changes occur in the throwing shoulder, which does not occur in the non-throwing shoulder. The changes that occur in young throwers are the result of the stresses inherent in the throwing motion. The presence of such high stresses on developing osseous and soft tissue structures makes the younger athlete more susceptible to injury. In addition, the tendency towards year-round play and playing for more than on team per season followed by all-star teams, travel teams and showcases all increase the stress on the developing body.
Overuse Injuries in Adolescents
We have come to know that elbow pain in the young athlete can be caused by several different pathologic processes, some minor and some more serious. In one study, 38% of almost 300 athletes studied suffered an arm injury, with slightly more shoulder than elbow injuries reported. Higher risk of shoulder injury was associated with increased age and weight but not increased height. Elbow injury was not associated with age, height or weight. Throwing curve balls was associated with higher rate of injury, as were year-round baseball activity, increased pitches thrown and increased innings pitched. A subsequent follow up report recommended limiting youth pitchers to 75 pitches per game and preventing them from throwing when they experienced fatigue or pain. The researchers evaluated over 400 pitchers 9 through 14 years old. They concluded that skeletally immature pitchers should be discouraged from throwing sliders or curve balls and that limitations on pitches per game and pitches per seasons should be initiated.
Recommendations
On the basis of some reports, recommendations have been made to track pitch counts for all pitchers at all levels and that breaking pitches (i.e., curve balls, sliders, etc.) should not be thrown until skeletal maturity. It has also been suggested that baseball participation should be limited to no more than nine months per year and that pitching should be limited to one team per season. In addition, pitch count limits were suggested per game and per season for ages 9 through 14, with gradual increases in each limit with progressive age and level of play. The table below outlines pitch-count recommendations for various pertain to pitches in competition and do not include warm-up throws, throws from other positions and practice throwing.
| Age | Per Game | Per Week | Per Session | Per Year |
|---|---|---|---|---|
| 9–10 years | 50 | 75 | 1000 | 2000 |
| 11–12 years | 75 | 100 | 1000 | 3000 |
| 13–14 years | 75 | 100 | 1000 | 3000 |
From USA Baseball Medical & Safety Advisory Committee: Position Statement on Youth Baseball Injuries, May 2006
Conclusions
Numerous studies over the past 15 years all point to the same conclusion: too much throwing is dangerous to the health of growing and developing athletes. If the goal is to continue to compete and play at subsequent and higher levels, heeding the advice of these authors seems like common sense. Yet the number of injuries continues to rise, as do the number of travel teams, showcases and multi-season leagues. In order to achieve success in baseball at higher levels, participation as a youth is likely required. However, we as parents, teacher, coaches, and physicians must temper our desire to see our children succeed by keeping in mind that there are limits to what their bodies are capable of.
Summary of Recommendations
- Throwing should not be painful. Persistent pain with throwing should be evaluated.
- Pitch counts per game and per season should be kept and adhered to for all levels of throwing.
- Pitchers should only pitch for one team per season.
- Multiple-season pitching is discouraged.
- Showcases, travel teams and all-star programs should be limited.
- Breaking pitches should be avoided until the cessation of growth.
