An Arm is a Terrible Thing to Waste
December 15th, 2008Three highly regarded Metro-area pitchers recently joined the ever-expanding list of Nebraska high school baseball players undergoing surgery on their throwing arms. Although the exact number of players added to that list in recent months is unknown, one of Omaha’s leading arm care physical therapists estimates the number to be in the range of 25-30 arm and shoulder surgeries in the past year. Of course, that doesn’t include the injured players whose baseball careers came to an early end because of sore arms and who didn’t fully discover the causes or chose not to have surgery.
Although the full extent of the arm injury epidemic may not be known, enough is known to be able to safely say that this a growing problem in need of solutions. Serious arm injuries such as ulnar collateral ligament tears (elbow) and labral lesions (shoulder) can have catastrophic consequences for a young ballplayer — potentially depriving him of the opportunity to pursue his dreams at this level and beyond. The real tragedy is that the vast majority of these injuries are preventable. The time has come to make prevention priority one.
What would a comprehensive throwing arm injury prevention program for Nebraska high school baseball look like? Here are some thoughts:
1. Education. The first order of business is for coaches, players and parents to educate themselves about how these injuries occur and how they can be prevented. Coaches are educators. Therefore, it makes sense for coaches to fully inform themselves about the problem and to use their skills as professional educators to TEACH their players how to avoid arm injuries. But it can’t all be put on the coach. Players and parents need to take responsibility for the health of the throwing arms in the family by learning as much as they can about sound arm care practices. Valuable learning resources can be found on the internet as well as among local professionals such as surgeons and physical therapists. The medical professionals in this area that we have talked to are very “prevention-oriented” and are more than willing to provide prescriptions for injury avoidance. Applying the old adage that “an ounce of prevention is worth a pound of cure,” it only makes sense to seek professional guidance before problems occur rather than after.
Educational activities can also involve group meetings of parents, players and coaches led by a physical therapist, orthopedic surgeon or other medical professionals who can outline prevention strategies and routines, injury identification and what to do when symptoms arise.
2. Preventative Exercises. Pre-season conditioning for throwers needs to include exercises specifically designed to strengthen key areas of the throwing arm that are vulnerable to injury, according to Metro area physical therapist Jerry Jacobi. For example, a conscientiously followed regimen of a few brief resistance exercises can build the rotator cuff muscles that stabilize the shoulder. Doing these exercises three or four times per week prior to the season and continuing them throughout the season can have tremendous benefits for shoulder injury prevention, according to Jacobi, an arm care specialist who has worked with many pitchers in the Metro area.
Skutt coach Shawn Exner is to be commended for instituting an arm strengthening program at Skutt, using a system called “Crossover Symmetry.” The key, according to Mr. Jacobi, is that players “actually do the exercises.” Integrating the arm strengthening exercises into the team’s daily warm up routine is a positive step — since many young players seem to lack the self-discipline to implement a sustained individual routine.
3. Avoiding Overuse. A study conducted by noted orthopedic surgeon James Andrews identified “overuse” as the number one risk factor for ulnar collateral ligament (elbow) injuries. Types of overuse can include year round throwing (less than two months of full rest from throwing each year), ”seasonal overuse” (routinely violating recommendations for maximum pitch counts or minimum rest - see chart below), and “event overuse” (short episodes of extreme overuse in which commonsense guidelines are grossly violated). Other risk factors included throwing breaking balls before age 14, having inadequate warm ups before pitching in a game and throwing a fastball in excess of 80 mph.
Andrews’ study was conducted by interviewing high school pitchers following “Tommy John” surgery to repair UCL injuries. He observed that many of his patients were playing competitive baseball eight or more months per year, were “top” pitchers who were routinely called upon by their coaches to throw a high pitch count to get the “big win,” often extended their throwing into the off-season in order to go to showcases and camps and whose parents often were tempted to allow overuse in pursuit of the goal of gaining the attention of college coaches, recruiters and scouts. Sound like anyone you know?
To curb the tendency towards overuse, Dr. Andrews published the following guidelines in his study for recommended maximum number of pitches and recommended rest days:

The governing body for Nebraska high school sports, the Nebraska School Activities Association, includes the following pitching limitations in its Baseball Manual:
• If an athlete pitched two innings on Monday and four innings on Tuesday, he would be eligible to pitch only six innings on Wednesday.
• If he pitched six innings on Wednesday and then did not pitch on Thursday, he would be limited to six innings on Friday. The number of innings pitched the two previous days must be taken into account in figuring the number of innings eligible to be pitched on the third day.
• The time of the day has no bearing on this rule. Two innings pitched on Monday in the morning would have the same effect on the example listed above as two innings pitched in the afternoon, no matter when the game on Wednesday was played.
The NSAA rules are inconsistent with Dr. Andrews’ recommendations in several respects. First, the pitching limits are expressing in “innings pitched” rather than “pitches thrown.” The number of pitches thrown in a given inning can vary greatly based on a number of factors. Most coaches and pitchers would be happy to get out of an inning by throwing only 10 to 12 pitches. Thus, twelve innings in three days might be in the range of 120 to 144 pitches under favorable circumstances and considerably higher if a pitcher struggles in any inning(s). Clearly, the NSAA rules permit (and probably encourage — especially during the post-season) throwing on short rest. Under the NSAA’s rules, if a pitcher throws six innings on Wednesday, he would be allowed to throw six more on Friday. Assuming that those six innings on Wednesday resulted in at least 60 pitches thrown (10 per inning), the pitcher should have three days rest according to Dr. Andrews, however, the NSAA rules require only one day rest. This scenario plays out on a big stage every year at the state tournament where some of the top arms on the team are brought back on short rest due to the high stakes involved and the number of games that must be won during a short period for a team to battle back through the loser’s bracket.
If coaches are unable to individually fight off the temptation to overuse a pitcher, do we need tougher outside rules and regulations to protect pitchers’ arms? As any reader of this publication knows, your author has little inclination to see the NSAA more actively involved in the administration of Nebraska high school baseball. Moreover, the NSAA-governed spring season represents less than one-half of the high school age-level baseball playing season in Nebraska. Stricter regulations from the NSAA would be beneficial in terms curbing post-season overruse, but would be meaningless for regulating pitcher overuse during the summer Legion baseball months.
Stricter pitching rules adopted by both the NSAA and the Nebraska American Legion would provide a year-round solution, but “command and control” regulation from the top down is rarely welcomed by the regulated community. Coaches and players are likely to resent (and look for ways to circumvent) such mandates.
A solution that is more likely to result in wider acceptance and implementation is a “bottom up” initiative that is driven by coaches, parents and players alike who desire to resolve this difficult issue that threatens the health of young ballplayers.
Can one school or program take the initiative to make arm health a priority on its own without sacrificing success on the ballfield? Implementing an aggressive arm injury prevention program at the individual program level is a little bit like unilateral nuclear disarmament. If you give up your nuclear weapons without others reciprocating, you put yourself in danger of annihilation if no one follows your lead and joins you. The same thing is true in arm injury prevention. As long as other programs pursue a “win at all costs” agenda, the short term success of your program — as measured in wins and losses — is likely to take a hit.
Should that matter? Isn’t doing the “right thing,” always the right thing to do?
Being competitive by nature, most coaches are going to have a hard time implementing arm injury prevention measures — particularly those intended to address the overuse problem – if the likely outcome is losing more games. Recognition of this tendency suggests that the most successful approach is a “unified” one in which athletic directors, coaches and summer booster clubs representing the various teams band together to fight the problem of arm injuries jointly rather than separately.
Fighting the problem at the “macro level” means that some “body” with sufficient will and influence is going to get behind the effort and coordinate its implementation. A likely body to undertake this effort is the Nebraska Baseball Coaches Assocation. Generally speaking, this organization at present is not strong in terms of membership or leadership. But tackling a very visible problem that threatens young athletes is just the kind of mission that could focus and reinvigorate this organization. Moreover, that organization, if sufficiently engaged in attacking this problem, would have the clout and the influence to make sure that youth level select team coaches became aware of the problem and joined their efforts to address it. Clearly, overuse at the youth level is a raging problem that needs to be reigned in.
Throwing arm injuries are not going to be eradicated any time soon, if ever, but certainly there is much that can be done to reduce the scope and frequency of the problem. It’s time to get started.