Injury prevention tips

1. Watch and respond to signs of fatigue

As a 2009 study by ASMI⁷ notes, like pain (see #8 below), "fatigue is generally difficult to quantify because it is a subjective measure that varies among persons." The study recommends using pitch counts, ball velocity, ball location, pitching mechanics, and strength as guides to determining fatigue.

• If a youth pitcher complains of being tired or looks tired, let him rest from pitching and other throwing:
• Like most athletes, pitchers are generally reluctant to tell coaches they feel tired, even when not telling might hurt both the team and the player;
• A pitching coach's observational skills and judgment need to be used to detect fatigue:
  • a tired pitcher exhibits significantly less maximum shoulder rotation and knee flexion and a slightly more upright trunk position at ball release:
  • a tired pitcher's fastball becomes consistently elevated.  One pitching expert says that as a general rule if a young pitcher unintentionally elevates his fastball significantly (4-6 inches) for two hitters in a row, a visit to the mound is in order. If the pitcher fails to make an adjustment on hitter #3, he takes him out.
  • a tired pitcher throws from a different arm slot/angle.
  • a tired pitcher begins to miss locations high and low; pitches wild high and inside to the arm side and wild low and outside to the glove side, says pitching coach Ron Wolforth, are "almost always a sign of significant fatigue and mechanical inefficiency." 
  • tired pitchers rely less on the lower body and more on the arm (which puts more strain on the arm)
  • tired pitchers experience a drop in velocity.  One prominent baseball expert recommends taking a pitcher out when the drop of average radar velocity exceeds 3% mph.  (although the use of radar guns is not generally recommended; see #9 below).

2. Make sure your child takes a break from pitching/overhand throwing

Research shows that youth baseball pitchers who pitch competitively more than 8 months a year are 5 times more likely to require surgery than those who take at least a four month break from throwing. 

This is particularly true for pitchers in warm-weather climates, who tend to play more months of the year than those in cold-weather climates. A 2011 study⁶ found relative weakness of the rotator cuff of shoulders of warm-weather pitchers and an inverse and negative relationship between the number of months spent pitching and internal rotation range of motion and external rotation strength,  The authors concluded that warm-weather pitchers were a "previously unrecognized, [but] vulnerable population in terms of their injury risk."

To reduce the risk of injury, youth baseball pitchers need a period of "active rest" after the baseball season ends and before the next season begins during which they should stay physically active to maintain conditioning, but refrain from overhand throwing of any kind:

• "Active rest" and no overhead throwing of any kind for at least 2-3 months per year (4 months is better, and is what USA Basebal and MLB now recommend in their Pitch Smart program). In other words, not only should a baseball player not participate in throwing drills, but he should not participate in other activities that put stress on the shoulder (javelin throwing, football quarterback, softball, competitive swimming etc.)
• No competitive baseball pitching for at least 4 months per year.

The 2011 position statement on overuse injuries⁴ by the National Athletic Trainers' Association recommends that "[a]dults ... ensure that pediatric athletes play only 1 overhead throwing sport at a time and avoid playing that sport year round."

The American Academy of Pediatrics' 2012 Policy Statement on Baseball and Softball¹⁴  likewise states that "Youth pitchers should not pitch competitively in more than 8 months in any 12-month period, and recommend 3 consecutive months of complete rest from pitching each year. (USA Baseball/MLB recommend at least 2 to 3 consecutive months off)

3. Follow pitch count limits and rest periods

Based on research showing a strong link between the number of pitches thrown and increased risk of arm injury, Little League Baseball instituted daily pitch limits and mandatory rest periods between pitching appearances in 2007, which it updated for the 2010 spring season.

Dr. James Andrews of ASMI, perhaps the world's foremost authority on pitching injuries, hailed the Little League pitch limit and rest rules as "one of the most important injury prevention steps ever initiated in youth baseball," although he warns that pitch counts alone can't protect UCL's from poor mechanics (see #5 below).

USA Baseball⁸ recommends pitch limits but does not mandate them.  A 2012 study¹³ found that knowledge of the pitch limits among youth baseball coaches, however, was poor, putting youth pitchers at increased risk for upper extremity pain and injuries.

The low percentages of coaches answering the pitching guideline questions correctly "are concerning, as it is quite difficult for coaches to accurately follow guidelines with which they are not familiar," noted the study.

In its 2011 position statement on overuse injuries,⁴ the National Athletic Trainers' Association recommends the following general limits:

• No more than 75 pitches per game for players 9 to 14 (90 pitches for pitchers between 15 and 18)
• Avoid pitching more than 600 pitches per season and 2000 to 3000 pitches per year (9- to 14-year olds)
• Pitchers between 15 and 18 years of age should throw no more than 90 pitches per game and pitch no more than 2 games per week. 

There are currently no pitch-count limits in high school baseball, but Dr. Andrews believes there should be.  "I have heard of kids who throw 160 pitches in a game, and that's just not safe," he told ESPN.com in a February 2012 interview.  He also says pitchers should never pitch on back-to-back days.  

A note of extreme caution to parents of youth baseball pitchers on independent travel and all-star teams competing in independently-operated tournaments: they may have NO rules at all on pitch limits and rest. Such travel, "elite" or "select" baseball programs have been subject to considerable criticism, including Little League's 2011 study on pitching injuries.

Dr. Andrews identified travel ball as a big cause for fatigue because coaches from different teams do not communicate with each other.  "One coach will pitch a kid for five innings one night and then the next day the same kid will go throw five more innings for a different coach in a different game," Andrews told ESPN.com.  "These pitchers should not be playing in more than one league at once. You have to rest to prevent these injuries." 

If parents allow their child to play on more than one team at a time (see #4), it will likely be up to parents to track their child's pitch counts so they don't exceed recommended limits.

The 2012 study¹³ showing poor knowledge of the USA Baseball pitching limit recommendations only makes monitoring by parents all the more critical.  Statistics recently published by Safe Kids International found that nearly half (45%) of youth baseball pitchers pitched in a league with no pitch limits, nearly as many (43.5%) pitched on consecutive days, and 19% pitched multiple games on the same day.

4. Avoid allowing your child to pitch on multiple teams with overlapping seasons

More and more youth baseball players play on multiple teams at the same time. While doing so may give him/her more opportunities to develop his skills, and while the amount of pitching may be limited by league rule or the judgment of the coaches, playing on multiple teams with overlapping seasons increases the risk that he/she may end up exceeding pitch limits (or the 100 inning limit recommended by ASMI in its 2010 study⁵) because of a lack of communication and coordination between coaches, who are likely to end up blaming each other if your child suffers an arm injury. 

The American Academy of Pediatrics' 2012 revised Policy Statement¹⁴ says "Young pitchers should avoid pitching on multiple teams with overlapping seasons," and calls for the enforcement of rest requirements across all teams.

If you do let your child play on more than one team at once, it may be up to you, as his parent, to keep track your child's pitch counts and days off and to insist that the coaches not exceed those overall limits.

The 2011 Little League pitching injury study emphasized the importance of explaining to "coaches, parents and players the high risk and limited reward of travel ball and showcases."

Again, the statistics are not encouraging: statistics from Safe Kids International suggest that nearly a third (30.4%) of youth baseball pitchers pitch with mutliple teams, and 13.2% pitched year round.

5. Teach good throwing mechanics as early as possible

Poor pitching mechanics can put additional stress on a young arm and increase the risk of injury, experts say.

It will come as no surprise to anyone who watches youth and high school baseball with any regularity that pitchers in their teens have better throwing mechanics than younger pitchers. 

A video analysis of youth pitchers reported in a 2009 article in the American Journal of Sports Medicine⁹ confirmed that adolescent pitchers (ages 14 to 18) performed better than youth pitchers (ages 9 to 13) on five simple measures of pitching mechanics (leading with the hips, hand-on-top position, arm in throwing position, closed-shoulder position, and stride foot toward home plate).  The pitching motions of fully eight out of ten adolescent pitchers  met 3 or more parameters compared with just two-thirds of the younger age group (although, unexpectedly, youth pitchers (86%) outperformed their older counterparts (66%) on the stride foot toward home plate measure).

The study suggests that the five measures of pitching mechanics studied may be developmental milestones for youth pitchers as they improve their mechanics over the years and learn to pitch, although it is unclear whether the development is a function of coaching and instruction or whether athletes more easily perform them as neuromuscular function improves with age.

Proper positioning of the throwing arm during all phases of the pitching motion can reduce the number of injuries. According to Thomas J. Gill, M.D., an orthopedist at the Massachusetts General Hospital and Boston Red Sox team physician. "Pitcher's arm movements during different phases of the pitching motion, if performed incorrectly, can cause injury," he says.

Researchers identified four problem areas:  

• Maximum shoulder rotation: A pitcher needs to rotate his body more to avoid placing too much stress on the arm and shoulder, which occurs when his arm is positioned too far behind his body.
• Improper elbow angle: The pitcher's arm needs to be away from his body when the ball is released; the closer the arm is to the body, the more potential for injury.
• Arm lagging behind the body: When a pitcher gets tired, his arm tends to lag behind his body, placing undue stress on the shoulder.
• Excessive ball speed: Trying to throw too hard can be harmful, especially for young players, warns Dr. Gill.  The 2006 ASMI study³ says pitchers whose fastball speed is greater than 85 mph are two and a half more likely to be injured.  A 2012 study¹⁵ by researchers at the Mayo Clinic and Mayo Clinic and the Kerlen-Jobe Orthopedic Clinic in Los Angeles found a very strong link between pitching velocity and peak stress on the elbow, suggesting that pitchers with greater throwing velocities may be more vulnerable to elbow injury, particularly of the ulnar collateral ligament (UCL).

Players should follow a step-by-step approach to learning how to pitch:

1. Basic throwing;
2. Fastball pitching. At all levels of competition, a good fastball is the foundation for successful pitching; thus, the young baseball pitcher should master the fastball first;
3. Change-up pitching.  Studies show it places the least amount of stress on the arm;
4. Curve ball (see #12 below)

Use of lighter balls may lessen the risk of overuse injury in pitchers between ages 9 and 12.