In 1974, a 31-year-old pitcher for the Los Angeles Dodgers underwent a new procedure to repair the ulnar collateral ligament (UCL) in his left elbow. His name was Tommy John, and so would become the name of the surgery. Today, it’s not unheard of for baseball players to get Tommy John surgery before they turn 20. One factor is, it’s become the norm for many child athletes to specialize, for example, playing baseball not just during Little League season, but throughout the year. With that has come an upward trend in upper extremity injuries, and elbow and shoulder surgeries as adolescents.
Dr. Cory Edgar, UConn Health orthopedic surgeon and co-director of the UConn Institute for Sports Medicine, joins Dr. Anthony Alessi to discuss youth sports injuries, the risks of playing a sport year-round with no downtime, the importance of pitch counts, and what parents might consider when it comes to their children’s participation in youth sports.
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Support comes from UConn Health Orthopedics and Sports Medicine and Coverys.
Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up-to-date, timely medical information provided by national and international experts in their field. This podcast is brought to you by UConn Health with support from the Department of Orthopaedic Surgery and a grant from Coverys. It is not designed to in any way direct your personal healthcare, which should only be done by your physician.
I’m your host, Dr. Anthony Alessi, and it’s great to have as my guest today Dr. Cory Edgar. Dr. Edgar is an MD, Ph.D. He is associate professor of orthopedic surgery here at UConn Health, where he also serves as co-director for the UConn Institute for Sports Medicine. He’s also a team physician. Cory, welcome to the show.
Dr. Edgar: Thank you, Tony. Always a pleasure to talk to you and be on the show.
Dr. Alessi: Let’s talk a little bit about Little League sports. And something we’re always hearing about is throwing injuries in athletes who are younger and younger, and I know that you treat a lot of these in athletes — We talk about Little League, but in all throwing sports. So I really want to emphasize today on upper extremity injuries. My first question is, are we seeing an upward trend in these injuries in general, and especially in a younger population?
Dr. Edgar: Yeah, great question. So overall, we have been seeing a trend in injuries, specifically around the elbow, and also the shoulder, with an uptick in people that need surgical intervention.
Interestingly, some of the newer data that’s come out suggests that this is trending surgery towards a younger throwing athlete, such that up to 60% of all the UCL reconstructions or Tommy John surgeries that we do on the young throwing elbow is now in the age bracket of age less than 20. So we’re seeing an uptick in injuries to the elbow and the shoulder in younger athletes for a variety of reasons.
Dr. Alessi: Let’s talk a little bit about the reasons. Is it because, I mean, it used to be, people played Little League, children played Little League, and that was it, the end of the season, some playoff, everybody got a trophy. But now we’re hearing a lot about travel, and you and I have talked about this at ringside and on the sideline over the years. I mean, it’s now Little League, sectionals, championship, travel, things like that. And in addition to increased expense for parents, it’s also been increased wear and tear on these arms. Is that one of the reasons that we’re facing this problem now?
Dr. Edgar: 100%, that’s the primary reason. I think we can talk about differences from region and weather-related and stuff like that, but the No. 1 reason is based on the amount that these kids are playing. There’s really no downtime for a lot of them. With travel baseball, and certainly in Little League and some of the more monitored associated programs, there are pitch count institutions that really help preserve the amount of exposure that these kids have. But when you get in the travel world, which, I have a kid that participates in travel baseball, you can go to a weekend tournament, the kids can play upwards of five, six, seven, eight games, play multiple positions in which they’re throwing regularly, not just pitching, but pitcher, now to catcher, now going to the outfield, and so there’s a lot of use to that arm. So overuse and tired forearms that now put stress across the elbow is what we’re seeing, and this is what we’re getting.
Dr. Alessi: So Cory, is there a difference when we see young athletes who play in the north where we have winter, and athletes who live in Florida and in the South, where it’s warm year-round and they’re playing baseball year-round?
Dr. Edgar: Yes, yes, there is. We often see Tommy John surgeries in the southern states over the life of an athlete go up. That said, in New England or areas in which there’s kind of extremes of weather changes where you can’t really play baseball regularly in the winter, we’re forced to go indoors, and it kind of forces a shutdown.
So there is this phenomenon that we and others are doing some research in, this start-stop phenomenon. So we see an uptick in the early parts of baseball season, so the Januaries, Februaries, and Marches, when the kids maybe get outside, they try to throw, it’s cold, and we see an uptick in the skeletally immature athlete or the little leaguer’s elbow.
So we’re trying to allow kids to play other sports and be diversified, but they still need to throw. Meaning throw the football, safe, have a catch one or two days a week, and it keeps mild stress across the elbow and strengthening to the flexor pronator mass so it protects them when they, quote unquote, “jump back into things” because they just go back into it really quickly.
And I’ll come up with a program where there’s kind of a throwing transition that happens, so that way there’s a much less risk of acute injury.
Dr. Alessi: Cory, I find that amazing, ’cause I thought you were going to talk the other way and tell us that you see more injuries in people who play year-round and in the South. So that’s fascinating, and I’m sure we look forward to the results of that research.
Alright, so when we’re looking at throwing injuries, are we talking about because they’re throwing harder? The old thought used to be that you didn’t want a young pitcher to throw curve balls and stuff ’cause they were stressing their elbow more, or is it purely just the number of pitches regardless of velocity and technique?
Dr. Edgar: A lot to unpack there. So yes, so I think there’s multiple things. Chasing velo is definitely becoming part of our culture, chasing velocity. And the kids, when we were kids, we were just competing against other kids. Now we’re competing against ourselves and just chasing numbers, with all the information that we’re given with TrackMans or just radar guns. These kids are into it early. So that’s one.
Two, the type of pitches that we throw probably doesn’t make as much as different as the technique by which we’re throwing them. So I think having a young kid that still doesn’t have the ability to grip the ball well and is can’t get through a fastball, and now you’re asking them to throw a curve ball, maybe it’s more a mechanics issue, but purely throwing a curve ball as a thrower in the age of skeletally immature 10 through 14, that’s not the danger. One pitch that we do see a higher risk is what we call a power change, when they actually pronate, or the palm goes down as they throw the baseball, ’cause that disengages the protective muscle or the flexor pronator mass, the big wad of tissue on the inside of your elbow that attaches to that bony prominence called the medial epicondyle.
Dr. Alessi: When we’re thinking about this, we’ve been talking about Little League and overhand throwing, but are you seeing this in softball as well with underhand pitching, or softball throwers as well?
Dr. Edgar: 100% from pitching, totally different mechanics, not an issue in softball pitchers. In fact, they’re much more liberal in the amount of restrictions that we put on softball pitchers for that reason. Now, when they go to overhead throwing, the softball catcher, the outfielder, they still play a lot of games, and we can see really particular shoulder conditions with softball players is more common.
Dr. Alessi: Why is that? I mean, when I watch fast pitch softball players, like here at UConn, I mean, it looks like a tremendous amount of stress on their shoulder more than anything. I’m kind of surprised that we’re not seeing more injuries mechanically on the shoulder from a pitcher.
Dr. Edgar: If you think about how the kinetic chain generates velocity into a ball that you’re hurling towards a catcher and a batter, two totally different mechanisms, and the body is designed well for the torque that’s put on them with the shoulder in the softball motion. They’re generating a lot of power, they’re stopping quickly, and then everything follows through in a range of motion. And their deceleration phase is just swinging the arm back over the top. So the things that decelerate the shoulder in a pitcher, a baseball pitcher, depending on their kinematics, but with most mechanics, they’re coming across, and so those powerful decelerators are your lat, your posterior shoulder muscles, and they have a lot of force that is trying to stop that arm from going forward and then coming across their body, so two totally different throwing mechanics.
Dr. Alessi: What about other injuries that parents need to be aware of in Little League, in terms of lower extremity injuries, are these an issue? I primarily see when they get hit with a comebacker, if they get hit in the head, but fortunately they do wear, pitchers do wear helmets at the younger levels. What other injuries should parents be aware of?
Dr. Edgar: Knock on wood, there’s the usual stuff, you know, the knee injury, the ankle injury. Baseball specific, I think the catastrophic ones, as you kind of mentioned, the comebackers. So getting hit in the chest, I think if anybody sees a kid get hit in the chest and goes down right away, you have to think that there’s an immediate cardiac issue because that can happen. The pitcher can have it. The batter can have it. Eyewear, you can get hit in the orbital, like, all those things are sort of specific dangers for baseball.
But overall, I think arm care, shoulder care is really what we’re dealing with these young kids because we’re trying to, to protect them with the amount that they’re playing, what we’re asking their bodies to take on.
Dr. Alessi: Alright, so here’s what we need to know. What do parents need to know in terms of, what should they do when their child is now doing this? Should they... First of all, I always believe in interviewing the coach and find out what their philosophy is, but what should parents know? What should they be doing? I know that many of us have advocated for playing different sports.
In other words, not just throwing year-round, like some people are, but what do you think parents should be doing?
Dr. Edgar: So two things that you brought up that I think is excellent. So obviously, myself included with my 12-year-old, we all think our kid’s going to have the ability to play in college. So we tend to migrate to that sport and what we call sports specialization becomes early. My kid’s a baseball player, that my kid’s going to play baseball year-round.
The data clearly says that, two things, one, Geno says it all the time, and the data backs him up, that people that are more athletic, meaning play multiple sports, the likelihood that they play a sport in college is, I think, three times greater than just the person that from a young age has focused on that one sport. Athleticism, strength is all key, and that also helps with the wear and tear on a body doing the same repetitive activities. Baseball is very different from a demand standpoint than football, than basketball, than soccer. Now, there’s overlap, but having that diversification gives a little bit of rest, gives the body time to stress another area where another area is recovering.
I personally think, and I’ve seen from experience, my own and with patients, understanding who your kid plays for is really important. I think little leagues, you know, they’re all the dads trying to do their best. That’s not really where we’re going to see it. We’re going to see it when you start to pay money for coaching, when you start to, like, one-on-one coaching, or you start to pay money for, in particular, travel baseball. Is this travel baseball program or coaching invested in our kids getting better, learning the basics, becoming better baseball players, recovery, nutrition, strengthening programs, or do they just want to go out there and play a bunch of games, win a bunch of games, get a bunch of awards so that that program looks better, but at the cost of your child?
So I think that’s huge ’cause you’re, you’re paying money to get your son better, or daughter, better, and more exposure, but you want to limit the risk associated with that
Dr. Alessi: What’s the future look like, in terms of Little League? Are we seeing somewhat of a trend where people are becoming more aware of these injuries and avoiding them, either from the rules standpoint with pitch counts or parents becoming more aware?
Dr. Edgar: I would like to say yes. I think from a regulatory standpoint, the pitch counts that have been instituted in Little League have made a huge difference, meaning that you’re only allowed to pitch 85 pitches for a 12-year-old. If you pitch a certain number, you have to have a certain number of days’ rest. So that’s pretty regimented and pretty clear and pretty accepted.
Not at all applicable for the travel programs. I think parents still don’t really understand. It’s not often, it’s not that uncommon, rather, that people come into my office that have elbow pain that probably could be treated conservatively, and the parent is right away like, “Well, why don’t we just do the surgery now so that way he doesn’t have to get it done later?” Because it’s more convenient to do it when he’s 13 than it is when he’s 17, which obviously from a medical standpoint doesn’t make much sense, and we certainly have that conversation about all the behind-the-scenes on that one.
Dr. Alessi: With that, Cory, I just want to take time to thank you, and thank you for your time today, and thank you for everything you do for Little League athletes here at UConn Health in the Department of Orthopaedics.
Many thanks to my guest today, Dr. Cory Edgar. If you have any questions or ideas for future programs, you could reach out to me at healthyrounds@uchc.edu. Jennifer Walker is the executive producer for the Healthy Rounds Podcast. Chris DeFrancesco is our studio producer who puts all this together.
Until next time, this is Dr. Anthony Alessi. Please stay healthy.
