Pitching Injury Diagnosis Help


#1

My 12 y/o son indicated that he had soreness (4/10 on the pain scale) above and below the elbow on the top of the arm after he pitched four innings in an indoor game last Wednesday. He did not mention this until the same symptoms occurred Saturday half-way through pitching practice however even though I asked him how his arm felt after Wednesday’s game.

The general consensus seems to be it’s muscular and probably brought on my too much, too soon. I couldn’t really find any pitching arm injury information that described his symptoms to a ‘T’, so I thought I’d come in here to ask if this rang any bells?

I plan on giving him a couple weeks off from pitching and then seeing if the problem reoccurs. If so, a trip to the ortho sounds in order, yes?

Thanks.


#2

You haven’t really given us enough info to offer any suggestions. For example, you think it might just be a matter of too much too soon. So, did he just start up after a lay-off? Did he just move up to a larger field? What has his workload been? What pitches does he throw? Does he play any other sports that involve an overhead throwing motion (e.g. volleyball, tennis, etc.)

Also, which side of the arm is the “top” side?


#3

[quote=“Roger”]You haven’t really given us enough info to offer any suggestions. For example, you think it might just be a matter of too much too soon. So, did he just start up after a lay-off? Did he just move up to a larger field? What has his workload been? What pitches does he throw? Does he play any other sports that involve an overhead throwing motion (e.g. volleyball, tennis, etc.)

Also, which side of the arm is the “top” side?[/quote]

Roger, sorry I didn’t give you enough to go on. I’ll try to dump everything about the situation I can think of here. Sorry if I ramble.

Yes, this was his first pitching outing in a game after about seven weeks of rest. His team has been focusing on mainly winter conditioning with some mild throwing. Pitchers have been doing bullpens about two times a week for the last three weeks or so.

His first game back last Wednesday, he pitched four innings. I didn’t keep his pitch count because an official scorer was used in the game. I will be keeping his pitch count from here on out with a pitch counter regardless.

He throws mainly four-seam, two-seam, circle-change, and sliders. He said he was very conservative with his sliders and that his arm pain occurred before he threw his first slider. I don’t condone him using his slider, nor does his pitching coach. But he likes to use it as his out pitch when he feels he can bewilder the batter.

He’s still pitching at 50 ft. He hasn’t moved up, but his velocity has improved a good bit from growth and rest. He throws with a low 3/4 arm slot. He swims. He said his arm still had discomfort swimming all strokes expect breast on Monday, so we’re halting that activity in the meantime while he ice and rest his arm.

He had a game last night where he just played first. He was very gentle with his arm and said he had no discomfort at all.

Finally, what I am referring to by the top side of the arm is if you hold your arm straight out with the back of your first pointing straight up the pain would be above and below the elbow joint not in the joint. The general consensus was his forearm was dipping below 90 degrees causing his arm to drag and putting excess strain on the arm. Not sure if that’s the case. Another kid on our team had the same issue last night, which I thought was odd.


#4

[quote=“pcarnette”]
Roger, sorry I didn’t give you enough to go on. I’ll try to dump everything about the situation I can think of here. Sorry if I ramble.

Yes, this was his first pitching outing in a game after about seven weeks of rest. His team has been focusing on mainly winter conditioning with some mild throwing. Pitchers have been doing bullpens about two times a week for the last three weeks or so.[/quote]
So really just 4 weeks of no pitching followed by 3 weeks of bullpens? This makes me wonder about long-term overuse. How long has he been playing? And before the mentioned period of rest, what was the longest contiguous chunk of rest he’s had and when did that occur?

[quote]His first game back last Wednesday, he pitched four innings. I didn’t keep his pitch count because an official scorer was used in the game. I will be keeping his pitch count from here on out with a pitch counter regardless.

He throws mainly four-seam, two-seam, circle-change, and sliders. He said he was very conservative with his sliders and that his arm pain occurred before he threw his first slider. I don’t condone him using his slider, nor does his pitching coach. But he likes to use it as his out pitch when he feels he can bewilder the batter.

He’s still pitching at 50 ft. He hasn’t moved up, but his velocity has improved a good bit from growth and rest. He throws with a low 3/4 arm slot. He swims. He said his arm still had discomfort swimming all strokes expect breast on Monday, so we’re halting that activity in the meantime while he ice and rest his arm.

He had a game last night where he just played first. He was very gentle with his arm and said he had no discomfort at all.

Finally, what I am referring to by the top side of the arm is if you hold your arm straight out with the back of your first pointing straight up the pain would be above and below the elbow joint not in the joint. The general consensus was his forearm was dipping below 90 degrees causing his arm to drag and putting excess strain on the arm. Not sure if that’s the case. Another kid on our team had the same issue last night, which I thought was odd.[/quote]
Usually I think of “above the elbow” as being closer to the shoulder (i.e. into the bicep muscle) and “below the elbow” as being closer to the hand. But your description makes it sound like what I would refer to as the outer and inner parts of the elbow. Can you clarify?


#5

[quote=“Roger”]
So really just 4 weeks of no pitching followed by 3 weeks of bullpens? This makes me wonder about long-term overuse. How long has he been playing? And before the mentioned period of rest, what was the longest contiguous chunk of rest he’s had and when did that occur?[/quote]

He’s been playing baseball since he was about six years old. He didn’t start pitching until he was 10. His pitching has ramped up over the last year. The long contiguous chunk of rest he’s had was probably two months and that occurred over this past summer.

[quote=“Roger”]
Usually I think of “above the elbow” as being closer to the shoulder (i.e. into the bicep muscle) and “below the elbow” as being closer to the hand. But your description makes it sound like what I would refer to as the outer and inner parts of the elbow. Can you clarify?[/quote]

What I am referring to is what you refer to as the outer and inner parts of the elbow.


#6

Ok, a 2 month break from pitching is good. The American Sports Medicine Institute (ASMI) recommends 2-3 contiguous months of rest each year for young pitchers.

Pain on the inside of the elbow is, unfortunately, fairly common for pitchers. That doesn’t mean it’s ok. It usually results from either overuse or a mechanical issue - or both.

Pain on the outside of the elbow is less common for pitchers. I’ve never actually encountered this and am not sure what would cause it aside from some mechanical issue.

So I guess I would agree with giving your son a couple weeks rest and then seeing how he is. But I would try to ease him back into it after that. I would also get his mechanics checked out to make sure he’s not doing something that would cause the pain to reoccur.

I also agree with you counting his pitches because he’s still young enough that you still need to be looking out for him. Also make sure he gets adequate rest between outings/bullpens.

One other question - do you know how many pitches he throws in his bullpens?


#7

Prevention of Arm Injury in Youth Baseball Pitchers, Kerut, Fleisig & Andrews, J. La. State. Med. Soc., VOL 160, March/April (2008).

Given the astronomical number of youth arm injuries I am seeing and hearing about in my parts (just heard about another 12 year old with elbow problems yesterday), I would take the above advice to not throw “for at least three months a year” as a minimum.

Someone once pointed out that “kids are not miniature MLB players and cannot train like they are”. I have taken that to heart. My son takes 4-5 months a year off from all throwing, plays soccer and basketball during the break, and returns to baseball unbelievably stronger and better. His friends and friends’ dads can’t believe he can take 4-5 months off and come back looking better than his friends, who pretty much play all year round. I suspect they’re mentally and physically worn out.


#8

Roger, south paw,

My thanks to you both! I have two follow up questions. The first is for my son’s age, 12U, about how many pitches should a bullpen consist of?

The second, is my son doesn’t really play another sport. He swims, but that is mainly a summer/winter activity where baseball is a spring/fall. So I was going to try to get him a 4-5 month window where we didn’t pitch until this winter indoor baseball thing crop up with his current team, but my intention was to break it into two 2-2.5 month breaks. The 4-5 month recommendation doesn’t really stress whether that break needs to be contiguous or not unless I missed it. So I guess my question is: Is two 2-2.5 as good as one 4-5 break. I would imagine so.

Thanks again.


#9

pcarnette,

The recommendation of experts to not throw “for at least three months a year” (or 4-5 months in my opinion) is contiguous months, that is, one right after the other. What I see a lot of is kids taking two months off in the late summer and one month off around Christmas, and calling it “three months off” … but those are the kids with arm problems.

P.S. A friend who played baseball with me in high school happens to be an orthopedic radiologist (MD from Duke Medical School) in a major southern US city. He specializes in arm injuries. It’s all he does. He sees countless youth arm injuries each year. He told me that if he had a son he would “Follow to a T” the recommendations of Dr. Andrews and his colleagues in Prevention of Arm Injury in Youth Baseball Pitchers, Kerut, Fleisig & Andrews, J. La. State. Med. Soc., VOL 160, March/April (2008), in particular the advice to not throw for several months of the year and play other sports.

P.S.S. It is also interesting how, with the rash of injuries to youth pitchers we’ve had around here (the ultimate being a 13-year old getting Tommy John surgery last summer), all the “pitching coaches” here who for the past several years have been advocating “curve balls thrown right” and virtually year round travel baseball, all of a sudden are not letting their own kids throw curves and are pulling back from year round travel ball. The chickens came home to roost.


#10

A lot of the recommendations for months of rest (yes, they do mean consecutive months of rest) are based on a model for pro pitchers.
To me, a pro who is throwing 200+ plus innings of high stress, high velocity pitching is much different than a kid who may be throwing a few innings.
Overuse is an issue in youth baseball certainly. Having kids play year round (and pitch year round) is an issue. I like that your son does not play baseball year round. Another sport or activity (like swimming) is great for kids in terms of just not athletic development but as people.
One issue I see a ton with kids with sore arms is a total lack of preparation. A lot of kids who play other sports don’t start thinking about baseball or pitching until a week before try outs. They go play catch once or twice then have a couple of practices (which are usually worthless) then are thrown into game situations. When my son was 14 he experience elbow pain in the same place you are describing. The doctor prescribed the usual (rest, ice etc)…which is to say he treated symptoms. I told my son not to pitch for the rest of that season (summer season) or fall ball. I took him to a good pitching coach who address some mechanical things he was doing and I put him (after several weeks rest) on a throwing program. Nothing crazy. Just a good warm up routine that included using bands, and long toss (playing catch if you prefer). So, after understanding how to warm up and throwing (not pitching) on a regular basis for months he has not had elbow pain since.
Pitching is a high stress activity if one if giving it their all. I don’t pretend there is one magic bullet answer to keep someone healthy. Some kids never practice, roll out of bed, go pitch and have no issues. Some do everything “right” and get injured. But, along with the discussion of rest (treating symptoms) and over use lack of preparation should be considered as well.


#11

Actually, the recommendation of several months rest in Prevention of Arm Injury in Youth Baseball Pitchers, Kerut, Fleisig & Andrews, J. La. State. Med. Soc., VOL 160, March/April (2008), is based on youth pitchers. Likewise, the position of ASMI - http://bit.ly/1jHFgGU - recommending several months rest is also based on youth pitchers.


#12

I understand they are recommending that for youth pitchers.
The movement toward several consecutive months of rest (I am not judging this as good or bad) originated in MLB as I understand it.
Just as the 120 foot limit on long toss originated in MLB as part of arm recovery (post injury) throwing program.
If they recommend 3 or 4 months rest for a kid as a blanket statement that is fine I guess but it does nothin to address lack of preparation which is a (not THE) root cause for a lot of kids.


#13

[quote=“pcarnette”]Roger, south paw,

My thanks to you both! I have two follow up questions. The first is for my son’s age, 12U, about how many pitches should a bullpen consist of?[/quote]
I would limit bullpens to 40-45 pitches. Keep in mind that pitches thrown during a game are broken up into innings with a half inning of rest every inning while pitches thrown during a bullpen tend to be thrown in one big contiguous inning with no rest.

[quote]The second, is my son doesn’t really play another sport. He swims, but that is mainly a summer/winter activity where baseball is a spring/fall. So I was going to try to get him a 4-5 month window where we didn’t pitch until this winter indoor baseball thing crop up with his current team, but my intention was to break it into two 2-2.5 month breaks. The 4-5 month recommendation doesn’t really stress whether that break needs to be contiguous or not unless I missed it. So I guess my question is: Is two 2-2.5 as good as one 4-5 break. I would imagine so.

Thanks again.[/quote]
One longer break is preferable to two smaller breaks. The youth skeletal system has soft growth plates which are vulnerable to injury (especially during growth spurts). Impacts and collisions can certainly injure the growth plates but so can overuse (both short-term and long-term overuse). Giving the growth plates time to repair themselves from the wear and tear (which seems to be cumulative) is important.

There can also be soft tissue (tendon and ligament) injuries and wear and tear. So, again, giving the body time to heal itself is important.


#14

MLB has always had an offseason of several consecutive months. The movement toward consecutive months of rest for youth pitchers originated with the 2008 study Prevention of Arm Injury in Youth Baseball Pitchers, Kerut, Fleisig & Andrews, J. La. State. Med. Soc., VOL 160, March/April (2008), which looked, inter alia, at the frequency of arm injuries in youth pitchers compared to the number of months per year the youth pitchers threw. It found that the control group of pitchers not needing arm surgery pitched an average of 5.5 months per year, while the group of pitchers needing arm surgery pitched an average of 7.9 months per year.


#15

Throw in dietary, physical, emotional and specific growth issues for pre pubescent boys and you’ve got a boiling pot of possible cause and effect that may never be clearly and completely understood.

Any participation in a group where you feel compelled to pitch your son based on his turn, his usefulness to a team win, his personal pride, your status, or a perceived financial gain or loss…any pressure other than his own best well being is adding to the risk factors.

The hardest thing to learn to say is the word, NO. The older he gets the more responsibility for that switches to him. The transition is another place where teens might more often get injured. Bottom line is pitchers have varying degrees of arm injury as long as they are pitchers and fathers and sons need to develop coping tools to help them make the adjustments necessary to continue pitching.

Keep searching, keep learning, make adjustments when you are convinced they will help. After you’ve done everything you can in the end your sons arm will determine if he keeps pitching.


#16

Southpaw…
Right, so we are in agreement then.

Dino…
What you’re saying is true. Every person is unique. Different things are going to work differently for different folks and everyone needs to find their own way.

A lot of guys seem to start with the arm issues around 12 to 14. Some younger but I hear a lot about boys in that age group. Why? I would assume that because of natural physical maturing they are able to throw harder and are more intense/competitive. Seeing an uptick in the stress put on the arm during pitching with no increase in preparedness is a big causer of ongoing or repetitive arm soreness in my humble opinion.
Seeing the same kids have sore arms year after year…and doing the same thing in response (ice, rest etc.)…it makes me a bit nuts to hear rest as the cure all for kids.
Rest allows for recovery and is needed of course, but, it does nothing to improve skill, strength, endurance that is needed to pitch.
would I give a kid months at a time off of the mound? Yes, for sure.
Would I give a kid months at a time away from throwing? No.
But, thats just me.


#17

That goes against the overwhelming consensus of the medical, scientific, and college/professional sports experts. In fact, I have not found a single medical, scientific, or college/professional sports expert who recommends not taking several months off from throwing.

Indeed, now even Major League Baseball, responding to the rash of Tommy John surgeries among mostly American MLB pitchers, recently issued pitching guidelines for youth that recommend:

http://m.mlb.com/pitchsmart/risk-factors/

So now even Major League Baseball is telling parents to have their kids take several months off each year from all throwing!

You’re entitled to your opinion, but with all due respect, there is no legitimate authority supporting it.


#18

No offense taken.
I know my opinion does not line up with the prevailing thought today.
Let me clarify a little what I am saying, or trying to say…
The statements papers that are out are coming from a very conservative perspective and I understand why and that makes sense.
However they are blanket statements. A kid who is throwing harder than average for his age group and is coming off of playing Fall, Spring and Summer ball where he was pitching a lot, obviously, he is due a good period of rest. A kid that is playing only summer ball and is getting an inning or two at a time (getting, lets say 15 or 18 innings over a summer) really has no reason to rest.
There could be other reasons a kid would take an extended break, wanting a mental break from the game or just doing other things, both of which are legit reasons for a break.
All I am saying is that a total four month break from throwing for a kid who spent 8 weeks pitching very occasionally is not really needed.
I love Eric Cressey’s stuff and I know he supports the total break from throwing for up to 4 months.
I love Kyle Boddy’s stuff and he does not.
The main point I was really trying to make however is that preparation is very rarely addressed with youth pitchers.


#19

I’ll throw my two cents worth in. I don’t see a reason for a total break in throwing. Believe Fearsomefour is correct about lack of prepardness. So many kids come into preseason with no throwing for extended periods of time, has to be a shock to the arm. I’ve seen same kids with arm problems year after year who only throw during the season.


#20

You keep using red herrings. When injuries from curve balls were being discussed, you argued that “overuse” causes injuries, ignoring the medical studies finding a much higher risk of injury for kids who throw curveballs than kids who don’t. Now, when injuries from year round throwing are being discussed, you argue that kids who do no “preseason preparation” get injured, ignoring the medical studies finding a much higher risk of injury for kids who throw year round.

Your arguments are red herrings because the fact that “overuse” and “lack of preseason preparation” can cause injuries has no bearing on whether curveballs and year round throwing can cause injuries too. You fail to appreciate that arm injuries can arise from different causes, and that a kid getting injured from “Cause A” does not mean that “Cause Z” cannot cause injuries in other kids.

As I write this, I know of 5 kids who are 13 to 14 years old in my baseball community alone who are right now sidelined with elbow injuries ranging from Medial Epicondylitis to Tommy John surgery. They all have one thing in common: year round baseball with no time off from throwing other than a few weeks in the summer and a couple weeks over Christmas. Lack of “preseason preparation” is not an issue for them … they don’t have a preseason.