Sports Participation for the Pediatric Thrower: How Much is Too Much?

One of our jobs as healthcare professionals is to encourage our patients - especially kids - to engage in healthy physical activity. It's been even more important lately as childhood obesity is reaching catastrophic levels. On top of growing inactivity and obesity, more and more athletes suffer sports injuries at a very young age. Why?

As a kid, I played many sports: soccer in the fall, basketball in the winter, and baseball in the spring and summer. These seasonal sports were spaced out throughout the year, so I had a break from each to enjoy the next. Now, kids are starting to specialize in a single sport at an early age.

As heavy sports participation goes up, athletes get injured at younger ages:

• Up to 30 to 40 percent of child and adolescent accidents occur during sports.¹

• Over 3.5 million children under the age of 14 are seen annually for sports-related injuries

These numbers are rising yearly.² With year-round competitions, young athletes take insufficient time off to rest and recover. Although prominent organizations^3-6 and professional journals^7,8 recommend up to 3 months a year away from a sport, many young athletes barely see 3 weeks of rest.

As throwing injuries increase in young athletes, the issue garners media coverage. Injuries often seen with professional athletes are increasingly occurring in skeletally immature athletes. Think about that! Kids who have been throwing for only one to two years are suffering the same injuries that professional pitchers get after years and years of throwing.

Why do throwing injuries occur?

In my experience, playing too frequently is the primary contributor to throwing injuries. Baseball players are often on three different baseball teams, with at least two seasons overlapping. They also rest from their sport for less than a week at a time, usually during school breaks or family vacations. Some of my patients threw a full game for one team and then pitched a game the very next day for another team. Tournaments get even worse: a pitcher may be closing his first game and then starting the next game that same day.

Research also recognizes higher injury rates:

• 18 to 69 percent of baseball athletes between the ages of 9-19 reported or will report elbow pain.⁹

• Over a third of baseball pitchers ages 9-14 reported shoulder pain in a single season.¹⁰

To put that into perspective, more than three of your nine starting baseball players will likely suffer an injury during the season.

Early signs

Be sure to collect a thorough history of the patient's sports participation. Ask the patient and family members about the athlete's current level of play, including:

• Number of teams the athlete plays on

• Last break from sports

• Positions

• Other sports

You'd be surprised how many patients say they take a break from overhead throwing but end up playing sports with a consistent overhead arm motion, such as tennis or swimming, leading to continued overuse.

How do I assess if my patient is at risk of injury?

Deficits in range of motion have been linked to increased incidence of injury. To monitor these deficits, you can use the following measurements:

• Glenohumeral range of motion, specifically internal rotation (IR) and external rotation (ER)

• Glenohumeral internal rotation deficit (GIRD) IR deficit of 20 degrees or more on the throwing arm vs. the non-throwing arm

• Total arc of motion (combined total range of motion, or IR + ER)

How do I interpret the measurements?

• If GIRD is greater than 20 degrees, the patient is at high risk of injury.

• If GIRD is greater than 18 degrees, injury is up to 1.9 times more likely.

• If GIRD is 11 degrees, injuries can still occur.¹¹

• If the total arc of motion deficit is short of 5 degrees or more on the throwing arm versus the non-throwing arm, the athlete has an increased risk of injury.¹²

My patient is at risk of injury. What now?

• Discuss with the patient and their family that decreased motion may lead to injuries.

• Prescribe a comprehensive home exercise program to the patient.

Prevention and clinical care

How can a patient minimize injuries?

It's essential that the athlete recognizes throwing arm discomfort early in their career, and takes the time to consider rest and recovery periods.

How long should a patient rest to recover from an injury?

Even with proper observation of signs and symptoms, the athlete can suffer injuries and require rest from the sport. Standards for rest periods vary for each injury and each patient. For instance, at least 4-6 weeks of rest from throwing is recommended for medial epicondylitis (aka Little League elbow), with possible return to full throwing in 12 weeks after a progressive interval throwing program.⁷

The rest period may seem long to the patient and their family, but it's a small sacrifice to ensure adequate healing and enjoyment of sports in the future. Discuss alternative exercises they can enjoy while the arm is healing (non-overhead sports, conditioning, cross-training, etc).

Who else should be involved in the athlete's rehabilitation?

Be sure to communicate this information to all stakeholders: patients, parents, and coaches. As the old saying, It takes a village to raise a child." The same is true for care of these injuries.

Prevention of throwing injuries in baseball

Pitch type

Talk to your athlete early on about the pitch types based on their age, and educate them about proper mechanics with all pitch types. Don't let their How to Throw a Curveball YouTube search do the work for you!

Stay up to date on the research. Here are the latest findings:

• Lyman et al. revealed that youth pitchers who throw a curveball or slider are 50 to 80 percent more likely to have elbow or shoulder pain. They even advise against pitchers between the ages of 9-14 throwing curveballs and sliders.¹⁴

• Other evidence revealed no increase in stress to the shoulder or elbow when throwing a curveball versus a fastball.¹⁵

Despite the conflicting views, coaches and parents should closely monitor a pitcher's throwing mechanics when the athlete is first introduced to throwing and when adding pitch types.

Table 1. Suggested Pitch Counts¹³

Age	Max. Pitches Per Game
7-8	50
9-10	75
11-12	85
13-16	95
17-18	105

Time off per season

At least three months. It's important to ask the athlete about the number of teams they're playing on and whether they have taken time off from that sport during the year.⁷

Table 2: Suggested rest periods

# of Pitches (Ages 7-14)	# of Pitches (Ages 15-18)	Rest Period (Days)
66	76+	4
51-65	61-75	3
36-50	46-60	2
21-35	31-45	1
1-20	1-30	0

Multiple sports and different positions

Young athletes who play multiple sports spaced out throughout the year have fewer injuries, play longer, and maintain a higher level of physical activity than those who specialize in a sport before puberty.⁶ Encourage this type of sports engagement in your athletes!

Also, discuss having your athletes avoid positions with higher throw counts. Studies found that a pitcher who was also a catcher was 2.7 times more likely to suffer an injury than a pitcher who didn't catch. Being a pitcher and first baseman instead, for example, decreases throwing episodes, increases playing time, and limits excessive throwing frequency.

Education with a skilled rehabilitation specialist

With pediatric throwing injuries on the rise, many resources have emerged to advance your expertise in these injuries. Check out the Medbridge course on Rehabilitation of the Overhead Throwing Athlete by Lenny Macrina for more information on clinical principles and treatment of throwing injuries.

Bumps and bruises come with the territory of rigorous physical activity. As caregivers for young athletes, we should educate ourselves about major contributing factors and ways to prevent these injuries.

Let's keep them out on the field and having fun!