Sideline Consult

A Radical Proposal for Reducing Baseball Pitching Injuries

Bert R. Mandelbaum, MD, DHL (Hon)

Disclosures

August 20, 2015

Tips for Avoiding Pitching Injury

Major League Baseball has a list of risk factors and tips for avoiding injury on its Pitch Smart website.[3] The league advises against:

  • Pitching while fatigued;

  • Throwing too many innings over the course of the year;

  • Not taking enough time off from baseball every year;

  • Pitching on consecutive days;

  • Excessive throwing when not pitching;

  • Playing for multiple teams at the same time;

  • Pitching with injuries to other body regions;

  • Not following proper strength and conditioning routines;

  • Not following safe practices while at showcases;

  • Throwing curveballs and sliders at a young age; and

  • Radar gun use.[3]

In addition to avoiding overuse of the joint, I'm hoping that we can develop conditioning routines that will reduce the risk for ulnar collateral injury.

My colleagues and I at the Fédération Internationale de Football Association (FIFA) were able to identify precise risk factors that contribute to anterior cruciate ligament (ACL) injuries in soccer. A particular problem was dynamic knee valgus. We built a conditioning program, the FIFA 11+, that could be used during warmup and showed that it could reduce not only ACL tears but also total injuries by 30%-70%.[4]

We don't have the information to develop a program like that for baseball yet because we don't have the smoking gun the way we did with the dynamic valgus.

Still, it's important to make sure that pitchers do all their exercises, and particularly to work on building strength symmetrically. Personally, I think that when conditioning is done right, you're going to get a benefit. But I welcome controlled studies, because we're not sure yet that they are going to show an impact.

Good News Regarding Treatment

While we continue to work on prevention, we have made a lot of progress in treatment. A wide number of procedures are being done by specialists, and overall the results have been very successful.

Although there haven't been any controlled trials, a number of case series have been done on Tommy John surgery, a surgical graft procedure in which the ulnar collateral ligament in the medial elbow is replaced with a tendon from elsewhere in the body. The best estimates suggest that about 70% of the time, people get back to pitching.[5] However, these results are not definitive.

But those who do come back appear to retain their abilities at the highest levels.

Last year, while I was director of research for Major League Baseball, I collaborated with Glenn S. Fleisig, PhD, and others on a study of 40-man- and non-40-man-roster players (on minor league baseball teams) who had undergone ulnar collateral ligament reconstruction, and 40 players who had no history of elbow or shoulder surgery.[5]

We thought we might find differences in biomechanics, such as a shortened stride or improper shoulder abduction and trunk lateral lift. But we didn't. In fact, we couldn't find any difference at all in the pitching motion of those who had the surgery and those who never had the surgery. We found no significant differences in elbow or shoulder angle, velocity, torque, or force between the two groups.

Still, there's no question that pitchers are better off when they don't need surgery. Let's hope that we can put in place more and better measures to stop these injuries from happening.

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