Sports Medicine Research: In the Lab & In the Field: Number of Games Over Number of Practices Primary Causal Factor for Elbow Pain (Sports Med Res)
Monday, November 25, 2013

Number of Games Over Number of Practices Primary Causal Factor for Elbow Pain

Elbow injuries in youth baseball players without prior elbow pain

Matsuura T, Suzue N, Kashiwaguchi S, Arisawa K, Yasui N. The Orthopaedic Journal of Sports Medicine. 2013;1(5):1-4.

Take Home Message: Up to 30% of youth baseball players may develop elbow pain yearly. Risk factors for elbow pain among youth baseball players is being older, playing as a pitcher or catcher, and/or playing more than 100 games a year.

There is a rapid rise in the rate of elbow injuries among youth baseball athletes. This may be attributable to many risk factors (e.g., immature skeleton, throwing mechanics, pitch type); however, there is little evidence to support these factors. We need to understand which factors may increase the risk of elbow pain among youth baseball athletes to implement prevention-conditioning programs and determine safe rules and regulations to prevent elbow injuries in this population. Therefore, the researchers investigated risk factors that could predispose youth baseball players without prior history of elbow pain to elbow injuries. Four hundred and forty-nine youth baseball players (mean 10.1 years of age, range 7-11 years) from a regional summer championship, who had no prior elbow pain, completed a questionnaire after 1 season (1 year). The athletes with the help of their coach and/or parent(s) answered if they experienced elbow pain during the season. The athletes also reported their playing position, practices per week, and number of games per year. If an athlete reported elbow pain, the authors recommended a physical examination (e.g., range of motion, tenderness, valgus stress test). Radiographic examinations were recommended to athletes who had a positive examination (e.g., 5o difference in range of motion between throwing and nonthrowing arm). Thirty percent of the youth baseball athletes (137 athletes) developed elbow pain over the one-year period. Among those athletes, 72% (99 athletes) presented abnormal findings during a physical examination. Athletes with elbow pain displayed limited elbow extension (32 athletes), limited elbow flexion (46 athletes), positive tenderness (65 athletes), and/or positive valgus stress test (44 athletes) during the physical examination. Eighty-six of the athlete with a positive physical examination agreed to undergo elbow radiography. Sixty-eight athletes exhibited medial epicondylar fragmentation and 2 athletes displayed osteochondritis dissecans of the capitellum. The authors found three key risk factors associated with developing elbow pain: 1) being 12 years of age compared with players under 10 years, 2) playing as a catcher or pitcher compared with an outfielder, and 3) playing over 100 games/year  compared with playing less than 50 games/year. The number of practice days per week was not related to developing elbow pain.

These authors demonstrated that around 30% of youth baseball athletes with no prior history of elbow pain may develop elbow pain within a year, and over 60% (86/127) of these cases will display abnormal radiographs. An intrinsic factor that could lead to elbow pain was being 12 years of age. Older youth athletes may begin to play more games, but it would be interesting to note if throwing mechanics or velocity changes as the athlete gets older. Position was an important extrinsic factor related to elbow pain, where pitchers and catchers have an increased risk for elbow pain. These two positions throw more than other field players so the volume of throws as well as their mechanics may help explain why these players are at greater risk. Additionally, playing more than 100 games/year increased the risk of elbow pain, which suggests that playing at such a high volume of games may not allow enough time for recovery. Together these findings may further support the hypothesis that players who expose their elbows to higher loads (e.g., older athletes, pitchers, catchers) and more repetitions (e.g., pitchers, catchers, playing over 100 games/year) may be at risk for elbow pain. One limitation of this study was that only youth baseball athletes that participated in the regional championship participated in this study. Therefore, this data may not be generalizable to other youth baseball athletes. Despite this limitation medical professionals should be aware of these risk factors, and ensure an inclusive history (e.g., position, how many games a year), and educate the athlete and parents about these risk factors to help prevent elbow injuries.

Questions for Discussion: In addition to pitch counts should there be catcher throw counts as well? Do you believe other factors may play a role in elbow pain such as pitching mechanics or physical conditioning?

Written by: Jane McDevitt, PhD
Reviewed by: Jeffrey Driban

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18 comments:

Nic Philpot said...

I feel like pitching mechanics should definitely be looked at when doing a study like this one. Poor mechanics are going to put an unneeded strain on their elbows at such a young age. Now that being said, its not necessarily practical to study enough youth baseball players mechanics. This is because of the amount of clinicians it would take in order to screen all of them. There is already a pitch count in most if not all youth baseball leagues. That number may need to be reduced if the majority of athletes are still getting elbow pain. It would be hard to put a pitch count on catchers because most youth baseball teams only have one kid who is willing to play catcher. It would also be interesting to look at the correlation between the age of the athlete, and the average number of games they play per year. The older an athlete gets, the more games they generally play in a calendar year. Does that play a role in the 12 year old's having more injuries? Or is it because they are throwing the ball harder the older they get, and thus putting more strain on their elbows? There definitely needs to be more research in order to to investigate further into this problem.

Jess Schlesman said...

I found this study to be very interesting because I feel as though youth sports are becoming more and more demanding. In all sports, not just baseball, younger athletes participate on travel teams or AAU teams, sometimes more than one team at a time and this doesn't allow for optimal recovery in between activity. I imagine this would cause later effects on the athlete's body as they progress and age. However, pertaining to this specific study, what are some things these young pitchers, and catchers can do to prevent this elbow pain without having to switch positions or skip games and practices?

Zach Johnson said...

This study is interesting, and I would like to see future epidemiological studies that look at youth baseball over long time periods. iIf we can find specific factors that play larger roles than others, it would be great to address these specific factors at youth levels to help prevent the number of overuse injuries. If there is evidence that playing pitcher or catcher, and playing over 100 games per year predispose youth athletes to elbow pain, then there has to be rules made to help prevent these risks. We need to educate parents about these risks. If they don't switch positions, they need rest days. if the team isn't large enough, they may need to switch positions. The parents and coaches need to understand the long term implications and not just think of the next game for these 10-12 year olds. I know there are guidelines, but if these guidelines are not helping in reduce injuries, then rules may need to be put in place to insure long term safety.

Jane McDevitt said...

Nic- I agree a mechanics study would be very beneficial and as equally difficult. I feel if there were a collaborative effort amongst several doctors and teams this could be done.

Jess & Zach- I agree the competitive level at youth sports is getting higher and higher. If there are risks with playing certain positions I think it would be a great idea to ensure that they are switching and gaining experience in other positions or resting that practice. I am not sure of the guidelines in place now, but I agree that if they are not stringent enough to prevent injury (especially in this young age group) then rule changes need to take place. As well as educating the parents about the short and possible long term problems that could arise from not adhering to the new guidelines.

Zach Johnson said...

I think the most they have for guidelines is links in the policies section of the little league website

http://www.littleleague.org/learn/rules/pitchpresentation.htm

Jane McDevitt said...

Zac-

Thank you! This is a very helpful link!

Shannon Snell said...

I think it would be interesting if they looked at practice time as well as games. Most youth athletes now attend multiple camps a year. Some even take private practice lessons on top of the camps, team practices, and team games. It would be extremely hard to incorporate all of that into a study and get all of the necessary information. However, I think it would help us determine how much truly is too much.

Jane McDevitt said...

Shannon,

That is a very good point. If researchers were able to control for the extra game/practice sessions (e.g., excluding those who participate in camps, private lessons), and still find that injuries occur. Then, they may be able to conclude that if athletes that play the "minimal" amount of baseball then those that play more would be at a higher risk. I am not sure there would be enough players that could fit this criteria, and there is still the mechanics aspect that would still be a limitation. It seems that this type of research would definitely benefit from a multi center approach!

Morgan Hooven said...

I think that there should be catcher throw counts just like pitcher counts. As stated in the study, pitchers and catchers throw way more then other positions in baseball. The amount of catches and the position the elbow and arm are in can cause alterations and pain. Also, I agree with Jess. Many athletes play on more then one team and do not leave time for recovery between games and practices. The lack of recovery time can cause added stress and strain on the elbow. Do you think athletes who participate in more then one sports team are more prone to injury then those who only play on one team?

Jess Schlesman said...

I agree, at that young of an age, it is the responsibility of the parents and coaches to help prevent the injuries. Parents should be aware of the schedule they are creating for their children, and coaches should be aware of the demand they're placing on these young athletes. Thank you.

Jane McDevitt said...

Morgan,
You bring up a good point. Do athletes that play more than 1 sport year round have the same risk for injury? I believe that it depends if the sports have similar mechanics. For example, if an athlete was a QB in the fall and a pitcher in the spring I think are going to have similar problems to someone that pitches year round compared to someone that plays soccer in the fall and pitches in the spring. This would add a lot of variables to control for in research so this would be a difficult study, but one I would certainly like to read!

Kaitlyn Johnson said...

With kids starting to play sports competitively younger and younger this topic brings up some key points. With injuries as the elbow being reported at such a young age, they are predisposing themselves for more severe injuries as they get older. Starting at the young age with pitch counts can help these young athletes get the recovery time they need. Since the research showed that catchers are also among those with elbow injuries I feel that having catcher throw counts can be just as important. This also brings up the important question is there anything else that might be predisposing these athletes to elbow injury. Throwing mechanics can possible have a huge part on elbow injuries, especially if they are not getting the rest the need and if they do not have a coach showing them proper throwing techniques. Another point is if these athletes are training properly as well. Are these athletes doing any strengthening programs? This might also be something to look in to as well with younger athletes.

Alex Ruxton said...

I find this article very interesting because it raises good questions about kids who participate in sports. I believe pitchers should definitely be held at a pitch count. As the game continues and the pitch count rises, you don't want the athlete to fatigue and alter his pitching mechanics. I think educating coaches and parents could be beneficial in reducing the amount of elbow injuries with kids. The catcher is another position where they have a high volume of throws. The catcher also typically plays the entire game where as a pitcher may be taken out of the game. I think it would be a good idea to implement a throw count for catchers as well to protect their young arms.

Sylvia Thelemaque said...

First and foremost pitching mechanics should be a number one priority. Simply because it makes a difference, if a coach teaches how to pitch the improper way and a kid sticks with that way for a few years that becomes a learned technique. Not to say it may completely throw off there game but it is difficult to break a bad habit once you have been doing it for so many years.

There should definitely be catching count for catchers, there on their knees for 7-9 innings on top of that for practice possibly 2 hours. Your body can only take so much stress for so long.

Kerri Schmanek said...

I found it very interesting that mostly 12 year old boys were among the population reporting elbow pain. It makes sense with all of the factors attributed to the pain (playing over 100 games per year and being a pitcher or a catcher), but why 12 years old? The author mentioned in the article that elbow pain is more common in this age group because they throw harder and are playing more games. My question is, could it be a hormonal factor? Males go through puberty during this time period and hormones could be playing a factor in the development of muscle and bone structure (i.e. carrying angle) causing their throwing mechanics to be slightly altered/off without the athlete realizing these subtle changes in their biomechanics. Maybe they need to alter their throwing mechanics at this age as their bodies are changing in order to reduce injuries to the elbow. I'm also curious if they just turned 12 years old or are they pushing 13? In addition to the findings in the article, I believe hormonal changes may be another factor to look into along with the differences of throwing mechanics of a 12 year old boy pitcher/catcher compared to a 10 or 11 year old boy pitcher/catcher. Overall, I really enjoyed reading this article and it definitely made me think about the differences a year can make in health of a young athlete.

Jane McDevitt said...

Hey Keri,

You have a very valid point. I think future studies should look at hormone levels and its association to elbow pain in youth athletes. However, because they didnt look at hormones and still found 12 years old to be a risk factor I think other factors should be looked at as well to decrease risk. For example, are there more opportunities for 12 year old players (e.g., more leagues), and if so should there be a limit to how many teams a youth athlete can join. I was also wondering if there was a jump in the length of the field. Do they have to throw farther than they did when they were 10 or 11 because the field is larger?

Leslie M. Staines said...

I found this article review to be very interesting from a myriad of standpoints; initially as an observer, followed by that of an athlete, and finally as future athletic trainer. As an observer I was intrigued by the information presented before me, to find so many injuries at such a young age was slightly disturbing. One typically does not envision an athlete at the age of twelve to be so competitive as to sustain chronic injuries as severe as those seen by collegiate athletes who have been performing the same motions over and over again for at least a decade. As an athlete, it makes perfect sense that at the ripe age of twelve, an athlete would be sustaining these injuries. Now days, kids are initiating their athletic careers at an average age of five, some beginning as young as three. Unless these athletes are being coached by professionals within their sport, their mechanics have probably not been honed to that which they should be. Throwing mechanics are most certainly sloppy and unperfected typically until the athlete reaches collegiate level or that of a select team outside of the school environment. Thereby enabling the athlete to fall into bad habits and coincidentally developing chronic injuries. Finally, as an athletic trainer the area of biomechanics comes into full vision. As it was touched upon earlier, it becomes clearer now that not only is the individual typically not being coached correctly, they are also growing into their body as they continue to hit additional growth spurts. Their bodies are taking such repetitive hard hits of practice after practice that it is almost a certainty that these chronic issues will develop. In addition, I agree entirely with the positions and their increased likelihood of chronic elbow injury. As one previous commenter had mentioned, at about the age of twelve is when these athletes begin participating in more games than practices due to their inherent schedules. This allows for the outfield to spend most of their time watching the plays whereas the pitcher and catcher are involved in every one of them; thereby the outfield has less opportunity to incur injuries. My question is, with the increasing number of youth participating in baseball, they must all practice more on their foundation skills (primarily hitting and throwing) before focusing on a primary position. This being the case, should we expect to see more injuries out of all positions in the future?

Jane McDevitt said...

Leslie,

You brought up a very good point. Are youth athletes being exposed to all of the positions, or are they honing in on their favorite position. I think you are right that the pitcher, catcher, and infielders are going to get more throwing exposures during games and practices compared to the outfielders. I feel it would be best that those younger athletes be exposed equally to all positions. I would hope that with education, proper training, and new rule implementation such as pitch/throw counts that the incidence of elbow injuries will decrease.

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