TOMMY JOHNS ELBOW EPIDEMIC

“A new study found a dramatic increase in the number of adolescents undergoing “Tommy John” surgery to repair a pitching-related elbow injury in recent years, outstripping growth among major league pitchers. The study, performed by researchers at Columbia University Medical Center (CUMC), was published in the January online issue of the American Journal of Sports Medicine.

“Everybody who follows baseball is worried about the rise in Tommy John procedures in the major leagues, and rightly so,” said study leader Christopher S. Ahmad, MD, professor of orthopedic surgery at CUMC, head team physician for the New York Yankees and chief of sports medicine at NewYork-Presbyterian/Columbia. “But we should also be worried about the 6 million children and young adults in the US who play this game and are at risk for significant pitching-related injuries. We need to determine why these injuries are so common and what can be done to prevent them.”

Analyzing data from the New York Statewide Planning and Research Cooperative System, the researchers found that 444 patients underwent surgery to repair the UCL between 2002 and 2011. The median age of the patients, mostly male, was 21. During that period, the total volume of UCL surgeries increased nearly 200 percent, while the number of UCL reconstructions per 100,000 people tripled from 0.15 to 0.45. Almost all of the growth occurred in two age groups, 17- to 18-year-olds and 19- to 20-year-olds. Patients who are white and had private insurance were 25 times more likely to undergo UCL construction than blacks and Hispanics with government insurance.

Tommy John surgery has a high success rate, but full recovery can take a year or more. In many cases, UCL injuries can be treated effectively with rest, physical therapy, and nonsteroidal anti-inflammatory medications. While the increase in UCL reconstructions among professional athletes has been well documented, few studies have looked at the incidence among younger, non-professional athletes.

Dr. Ahmad suspects a major factor is the fiercely competitive culture of youth baseball, which encourages talented players to throw more frequently, with greater intensity, and at a younger age. The solution may be to provide more education about the risks of overuse throwing injuries and the importance of adherence to preventive guidelines, such as pitch-count limits.

In a previous study, Dr. Ahmad found that three-quarters of young players reported having arm pain while throwing, and almost half of all players had been encouraged at least once to continue playing despite having arm pain. Signs of injury include fatigue, pain, taking medicine for pain, and icing excessively.

“If a young player is hurting, he or she should not keep playing or pitching,” said Dr. Ahmad. “Kids, of course, think they’re indestructible. Parents and coaches are in a position to tell athletes when it’s time to give the arm a rest, and if they need to take a temporary break from baseball.”

Please see the publication for the complete report and References [‘Tommy John’ reconstructive surgeries on the rise among young athletes, March 7, 2016, Columbia University Medical Center]

“The number of injuries to Major League Baseball (MLB) pitchers, specifically injuries involving the ulnar collateral ligament (UCL), have been rising in recent years.8,19 The rate of elbow injuries and elbow surgeries in adolescent pitchers has also dramatically increased over this same time period.3,5 Studies have shown that the most common age group for undergoing a UCL reconstruction (UCLR) is between 15 and 19 years, and this rate has risen to the point of becoming an “epidemic.”3,5,7,11

“There have been multiple studies that have attempted to determine the cause of this increase in injury rates in adolescent pitchers.2,13,15 Several risk factors, including high pitch counts, pitch velocity, pitching year round, geography, loss of shoulder motion, elbow torque, sports specialization, and others, have been shown to increase a pitcher’s risk for injury.

“Sports specialization refers to a practice in which children choose a single sport to play, spend more than 8 months of the year participating that single sport, and often stop participation in all other sports.20,21 Recent studies have suggested that this practice increases rates of both injury and burnout.20,21

“However, despite empirical demonstration of these risk factors, to date, no study has demonstrated that strategies for injury rate reduction are effective.”

Please see the publication for the complete report and References[Erickson BJ, Chalmers PN, Axe MJ, Romeo AA. Exceeding Pitch Count Recommendations in Little League Baseball Increases the Chance of Requiring Tommy John Surgery as a Professional Baseball Pitcher. Orthopaedic Journal of Sports Medicine. 2017;5(3):2325967117695085. doi:10.1177/2325967117695085]

The following is the American Sports Medicine Institute Position Statement for Tommy John Injuries in Baseball Pitchers Updated September 2016:

“> EPIDEMIC

During the past few years there has been an “epidemic” rise in the number of professional pitchers requiring ulnar collateral ligament reconstruction (“Tommy John surgery”).1 This is like déjà vu, as a similar sharp rise was seen in adolescent pitchers near the turn of the century.2,3 These two rises are indeed connected; that is, today’s pro pitcher in his 20’s was an adolescent pitcher a dozen years ago. Thus in many cases, the injury leading to Tommy John surgery in today’s young pro pitchers actually began while they were adolescent amateurs. Observations by orthopaedic surgeons support this link, as the torn ulnar collateral ligament (UCL) in a pro pitcher usually looks like it has worn out over time.

RISK FACTORS FOR ADOLESCENT PITCHERS

Research has shown that the amount of competitive pitching and pitching while fatigued are strongly linked to injury.4,5,6 Other risk factors may include pitching on multiple teams,5 pitching year-round,6 playing catcher when not pitching,7 poor pitching mechanics,8,9 and poor physical conditioning.10,11 Recommendations for youth pitchers are shown on the ASMI Position Statement for Youth Pitchers.12

COMMON MISCONCEPTIONS ABOUT TOMMY JOHN SURGERY

“Pitchers should get Tommy John surgery as soon as possible, as they will be better and throw harder after the surgery.”
Even though a surprising 25% to 50% of amateur players, parents, and coaches believe this,13 it is not true. Indeed, MLB pitchers often show some improvement in performance upon return from Tommy John surgery.14 However such improvements for a professional or amateur pitcher are due to the surgeon fixing the problem followed by the pitcher working intensely with the physical therapist, athletic trainer, strength coach, and pitching coach. The time without pitching after surgery also helps the athlete’s body. Performance eventually decreases over time for MLB pitchers after Tommy John surgery (similar to the typical decrease over time for healthy MLB pitchers).14–16 It is also important to realize that 10% to 20% of pitchers never make it back to their previous level after Tommy John surgery.17,18 Furthermore, a recent study by MLB and ASMI showed no differences in pitching biomechanics between professional pitchers with a history of Tommy John surgery and professional pitchers with no history of injury.

“Too much pitching is a big reason for all of the Tommy John injuries these days.”
Exactly. When an orthopaedist performs surgery on a torn ulnar collateral ligament (“Tommy John” ligament), the surgeon will almost always see a ligament that has frayed over time from overuse and repetition. In previous generations, Major League pitchers grew up competitively pitching only a few months each year, but nowadays leagues and teams are available for adolescents to play competitive baseball almost all year. Research has shown a strong link between too much competitive pitching and arm injuries.4–7

“Throwing curveballs is a big risk factor for elbow injuries in young pitchers.”
While biomechanical research19–21 and epidemiologic research4,6,7,22 have not shown a strong connection between curveball and elbow injuries, a youth pitcher may not have enough physical maturity, neuromuscular control, and proper coaching instruction to throw a curveball with good mechanics. The first steps should be to learn, in order: 1) basic throwing, 2) fastball pitching, 3) change-up pitching.

“Lowering or eliminating the mound would reduce the stress on the elbow and reduce the number of UCL injuries.”

Current biomechanical studies disagree about whether elbow torque while throwing on flat ground is less, greater, or the same as when pitching on a mound.23–25 Regardless of mound height, the real solution is for young pitchers to do less full-effort pitching and more sub-maximal throwing (practice throws, playing other positions, playing other sports). To become a successful adult pitcher, the youth should not strive to be a “youth pitcher” but instead should be a young athlete that is a good pitcher.

“Baseball in Latin America must be doing something right, because the prevalence of Tommy John surgery is so low among professional pitchers from Latin America.”
Not true. A recent survey revealed no difference in the prevalence of Tommy John surgery between pitchers from the U.S. and pitchers from Latin America. The survey showed that 16% of U.S. born-pitchers and 16% of Latin American pitchers in professional baseball have a history of Tommy John surgery.

RECOMMENDATIONS FOR PROFESSIONAL PITCHERS AND TEAMS FOR REDUCING RISK OF TOMMY JOHN INJURY

Optimize pitching mechanics to ensure using the whole body in a coordinated sequence (kinetic chain). A biomechanical analysis is recommended, as it provides objective data to the pitching coach, strength coach, and pitcher. A biomechanical analysis can also serve as a baseline for re-evaluation later in the pitcher’s career, after performance improvement or after return from injury.

Vary speeds for each of your pitch types. This will not only reduce the overuse on the elbow, but also can be an effective strategy. The best professional pitchers pitch with a range of ball velocity, good ball movement, good control, and consistent mechanics among their pitches. The professional pitcher’s objectives are to prevent baserunners and runs, not to light up the radar gun.

Open communication between a pitcher and his professional coaching and medical staff is paramount. The pitcher’s elbow and body are living tissue. Pitching and training create small tears in the tissue; rest, nutrition, and hydration repair the tears. A pitcher and his team should have a plan, but that plan needs to be monitored and sometimes adjusted depending on how the pitcher feels. Specifically, the pitcher should keep his trainer or coach up to date about any soreness, stiffness, and pain. That way when there is an issue, the player and team can consider rest, modified activity, or examination from the team physician to allow the elbow to heal and avert serious injury.

The pitching coach needs to watch for signs of fatigue on the mound. This could be seen in-game as well as in bullpen sessions.

The team trainers, coaches, medical staff, and front office must share knowledge in a holistic approach to minimize the risk of injury.

Flat-ground throwing drills and bullpen sessions should not always be at maximum effort. Reduced effort will allow for physical fitness and technique without adding undue stress to the UCL.
Take off at least two consecutive months each year from all throwing. During this “active rest” period, you can do other physical activities and exercises, as well as continue proper nutrition. The UCL and body need time to recover and build strength, so the concept of annual periodization should include adequate rest from pitching.

Exercise, rest, and nutrition are vital for a pitcher’s health. Performance-Enhancing Drugs (PEDs) may enable the athlete to achieve disproportionately strong muscles that overwhelm the UCL and lead to injury.

Pitchers with high ball velocity are at increased risk of injury. The higher the ball velocity, the more important to follow the guidelines above.

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