The more frightening thing is the amount of patients that we don’t read about who are undergoing the same surgery. More and more, young baseball players ages 15-19 years old are sustaining this same injury and having to undergo this surgical procedure.

Ulnar collateral ligament reconstruction used to be an injury that we saw in ball players later in their careers. John Smoltz played for the Atlanta Braves and was recently inducted into the Baseball Hall of Fame. His career benefitted from Tommy John surgery. Currently, he's the only player inducted into the Hall of Fame who received Tommy John surgery. But he warns against the number of young people receiving the surgery today, calling it an "epidemic."

"I want to encourage the families and parents that are out there that this is not normal to have a surgery at 14 and 15 years old," Smoltz said. "That you have time, that baseball is not a year-round sport. That you have an opportunity to be athletic and play other sports. Don’t let the institutions that are out there running before you guaranteeing scholarship dollars and signing bonuses that this is the way….

I want to encourage you, if nothing else, know that your children’s passion and desire to play baseball is something that they can do without a competitive pitch. Every throw a kid makes today is a competitive pitch. They don’t go outside, they don’t have fun, they don’t throw enough — but they’re competing and maxing out too hard, too early, and that’s why we’re having these problems. Please, take care of those great future arms.”

So are his concerns warranted? In short, yes.

A recent study showed that 15-19 year-olds accounted for 56.7 percent of the ulnar collateral ligament reconstructions performed in the U.S. between 2007-2011.

This is a scary statistic considering this means that over half the UCL reconstructions done in the U.S. are performed on patients who haven’t finished their freshman year of college. So why has this become so much more prevalent in younger athletes?

I think the simple answer is the volume of pitches being thrown. If we look at the trends with today’s young baseball players, more often than not they are playing year round, playing on multiple teams, and at times playing on multiple teams at the same time. At some point kids have to put down the baseball and give their arm a break.

Little leaguers who pitch have a major disadvantage compared to their major league counterparts: they are still growing. This means that each time they take the mound they are pitching with a new body. As kids grow taller, it means they have longer limbs that they have to control, and this takes more strength and more coordination, strength and coordination that often doesn’t keep pace with how fast the athlete is growing.

So how do we reverse the trend of these young baseball players dealing with this terrible injury? Here are four recommendations.

1.Decrease the volume of throws

2.Don’t pitch with fatigue

3.Don’t throw breaking pitches (until skeletally mature enough and skilled enough to do it correctly)

4.Delay specialization (play multiple sports)

Decrease the volume of throws

Decreasing pitch volume I feel is the most important of these three recommendations. It’s not just following pitch counts it’s avoiding playing multiple positions with a high volume of throws. I have had many patients come in and say “we follow all the recommended pitch counts,” but as I dig deeper I find out that, yes, they are following pitch counts, but the child is playing catcher when he isn’t pitching. The bottom line is that it isn’t just pitch count alone, it is the total volume of throws we need to think about.

Don’t pitch with fatigue

Making sure our players aren’t pitching fatigued is also a big part of keeping our young throwers safe. If a player is fatigued and continues to pitch, even if they haven’t reached their pitch count, they are putting themselves at risk. The National Athletic Trainers’ Association (NATA) Position Statement on Prevention of Pediatric Overuse Injuries cited a study showing that a greater percentage of pitchers with shoulder or elbow injuries started at another position and pitched with arm fatigue. So if a player has been out in the hot sun playing short stop in the first game of a double header it probably isn’t a wise decision for him to pitch in the second game

Don’t throw breaking pitches (until physically mature enough and skilled enough to do it correctly)

I think most parents of young baseball players have at least heard the recommendations to avoid curveballs and sliders until the player is older, but for some reason we still have young pitchers throwing these breaking pitches. Another study cited in the NATA Position Statement on Prevention of Pediatric Overuse Injuries showed the risk of elbow pain increased 86 percent in youth pitchers throwing sliders, and the risk of shoulder pain increased 56 percent for pitchers throwing curveballs. We as parents need to remember our kids are going to watch their favorite big league pitcher and want to throw all the same pitches it is up to us as parents to step in and say you aren’t ready for that.

Delaying Specialization

There is an interesting study finding that more of the successful, Hall of Fame–type pitchers come from up north, where Hall of Fame hitters come from all over — a lot of them from the South. The gist of the study was that because there are several months of the year in these northern states that it is too cold to be outside playing baseball these pitchers couldn’t participate in baseball year round. During the winter months they had to put the baseball down and do something else. Once again referring back to the NATA’s position statement they state, “Young athletes who participate in a variety of sports tend to have fewer injuries and play longer, thereby maintaining a higher level of physical activity than those who specialize before puberty.” Delaying specialization is also a big part of decreasing volume, because if kids are playing another sport they will get that nice break that they need from throwing.

This blog by no means touches on all the factors that lead to these injuries, and the four recommendations are by no means the complete list of ways to prevent these injuries, but following these recommendations is a good place to start to keep, our young ball players’ arms nice and healthy.

Resources

• Baseball Injury Prevention
• Top 10 questions parents have about sports injuries
• Young athlete's injury prevention guide
• Strength training in children/adolescents

“Stop Slouching!”

Why is my kid’s posture so poor?

THE PROBLEM

Do you get sick and tired of telling your child to sit up straight? Do you ever wonder why so many kids these days have slouched posture and often complain of back pain?

Let’s take a moment to think about a child’s typical day during the week.

1. They spend six hours a day at a desk in school. Most of this time is spent writing notes or typing with their hands in front of them and their head looking down.
2. When they are not in school, much time is spent playing video games, playing on their smartphones, surfing the Internet on the computer or texting. Again, arms are in front of them and head is down
3. They carry around a backpack that often weighs almost as much as they do and often times wear it low, resting on their low back or bottom. Backpacks should weigh no more than 10 percent of their body weight, be worn on both shoulders and fit snuggly to their back.

In April of 2012 – Archives of Pediatric and Adolescent Medicine published an article stating that only 51 percent of children went outside to walk or play per day with either parent.

Another national study found that the average American age 8-18 plays video games for greater than 13 hours per week. Studies also show that children today spend half as much time outdoors as their parents did when they were young. These kids prefer to stay inside to watch TV, surf the Internet, listen to music and even do their homework, rather than go play outside.

How it affects the kids

The positions discussed above, which kids are in for a large majority of their day, place the muscles on the front of their chest into a shortened position. After a while, it is difficult to stretch those muscles back out to attain proper posture independently. Tight muscles on the front of their chest cause them to continue to sit with their shoulders rounded forward and thus the cycle continues. The muscles in the front of their neck also become tightened, pulling their head forward. A forward head can also cause the muscles at the base of the skull in the back of the head to become tense.

Unfortunately, the inactivity caused by the increased time spent indoors also contributes to a poor core. The core consists of the muscles around the center of your body that help your back stay up straight. Without an active core, it is very difficult to maintain good posture and fatigue will set in quickly. A weak core in combination with prolonged periods of inactivity will likely lead to a cycle that is difficult to break, causing poor posture.

What to do

Have a homework station set up for kids. Doing homework on the bed or floor often makes posture worse and increases the curvature of their back while they are sitting. Kids should sit in a chair where their feet can touch the floor and their hips and knees are at 90 degrees. The table height should be so that their forearms are able to rest comfortably while they are working so that their shoulders can relax.

They should be in the same sitting posture for the computer and the screen should be at eye-level to keep their head in a good position as well. There are shelves made to lift computer screens up to eye-level, however, a large dictionary will often do the trick, as well.

The American Heart Association’s recommendation for physical activity for children is at least 60 minutes of moderate-vigorous intensity aerobic activity at least every day. As a parent, try to encourage your child to be active for at least one hour a day, either at school or at home. If you cannot find the time for your child to perform 60 minutes of straight activity, try to perform at least 30 minutes of activity twice per day.

It is never normal for a child to experience back pain or consistent headaches. If your child is experiencing either of these symptoms and is not actively being treated by a healthcare provider, please discuss these concerns with their doctor. Physical therapy can assist with improving posture and core strength to eliminate back pain.

Related information

• Cook Children's Sports Performance Orthopedic Rehab Team Specialists (SPORTS)
• Dynamic stretching
• The basics of sports injury prevention for kids
• The essential backpack 

Water sports are great because it allows one to exercise at a high intensity, there is not that much stress on the back and legs. It is great for a whole body work out and allows someone, in one hour, to be able to burn as many calories as in a one-hour run.

Typically, one doesn’t think of swimming as a sport that leads to many injuries. Swimming is an overhead sport and the human body is not made to handle a lot of overhead activities. Swimming too much can lead to overuse injuries. The main ones are shoulders pain and occasionally knee pain.

The training for competitive swimmers has changed in recent years. Training now requires swimming a lot of laps. All this swimming leads to more overuse injuries, like the ones we see in baseball pitchers and runners. Shoulder pain is the major problem swimmers will “swim” into because using the same muscles over and over can lead to the muscles in the chest and back being unequally strong. These muscles not being equal can lead to bad swimming form which will then lead to shoulder pain. Swimming strokes that can lead to shoulder pain are freestyle, back stroke and butterfly. Swimmers that participate in breast stroke are as at risk as other strokes for shoulder pain, but can also develop knee pain. This comes from the knee cap shifting and rubbing on other parts of the knee joint leading to knee pain.

It is important for coaches and parents to know how to keep their young swimmers safe, what to look for, and what questions to ask their kids to ensure that they are staying safe and not injuring themselves.

KNOW WHAT’S BEST FOR YOUR YOUNG SWIMMER:

Parents and coaches can help their swimmers by being an extra pairs of eyes, because the young athletes don’t know any better.

Rest: Athletes participating in overhead activities should not participate in these activities for at least three months out of the year. This means that it is good for parents to encourage their child to try different sports, specifically ones that don’t involve overhead activities.

Warmup: Ensure that your swimmer is warmed up properly. It is never good to get into a pool cold. The type of warm up is important too. Make sure that the warm ups are active and not passive stretches. There are a lot of traditional stretches that swimmers do to warm up their arms. These warm ups target parts of the shoulders that keep the joint stable. It is important to warm up and actively stretch the muscles themselves and not the shoulder joint.

Hydration: Lastly, make sure to drink a lot of water. Being in a pool dehydrates the body on top of the sweating that occurs while working out.

THINGS TO AVOID:

• Incorrect swimming form
• Excessive training without rest days
• Swimming the same stroke every time

WHAT TO WATCH FOR:

• GREEN LIGHT- Good: Muscle soreness is OK if it last 2-3 days
• RED LIGHT- Bad: If soreness last more than 2-3 days, or gets worse, and/or is sharp

(If it is a red light item one should seek help from a medical professional)

NOW WHAT:

Young Kids AGE: 5-9

• Training should not exceed 60 minutes and no more than three times a week.
• Learn how to properly perform the basics of the strokes.

Older Kids AGE: 10-16

• Training should not exceed 120 minutes and no more than 6 times a week.
• Learning how to decrease wasted energy with strokes.

PROPER WARM UP:

• 5 minutes of light swimming
• 15 minutes of active stretching
• 10 minutes of stroke and breathing exercises in the pool

At Cook Children’s, our SPORTS physical therapists are trained in proper rehabilitation of overuse injuries and work to restore full function and safely guide return to athletic activities. If your child has a history of injuries from swimming or you are concerned about risk of future injury, talk to your pediatrician about a referral to physical therapy.

Learn more here:

• USA Swimming
• Ovoiding overuse injuries
• Swimming Injury Prevention

The answer is complicated.

Yes, it's very important for toddlers ages 1-3 to interact with other kids their age and challenge their balance, strength and coordination. Sports are a great way to promote these skills and literature shows that athletes who play sports at a younger age are more likely to be active adults than their peers who don't participate in sports.

However, organized sports  may not be the best solution for children 3 and under, and aren't the only way to teach our children these skills. The list below describes activities for toddlers and some benefits of these activities for their development.

Swimming: Helps strengthen the arms and legs, as well as improve coordination since the child has to use both arms and both legs at the same time. Learning swimming at an early age helps promote good water safety habits later in life. You can practice swimming in a "parent and me" swimming class. 

Dance: Improves balance, coordination, strength and flexibility. You can practice in a class setting or by having a "dance party" or playing a game of "freeze dance" at home.

Biking: Between ages 2 and 3, kids should be able to begin riding a tricycle. For young kids, there are tricycles that offer a parent guide bar to help kids move and steer. You can practice biking in your neighborhood or on trails.

Soccer: Most teams start between ages 3-5; however, kicking a ball in the backyard with your toddler is a great way to help them learn to run, develop core strength and balance on one foot for a short period of time.

Basketball: Helps kids develop hand-eye coordination when dribbling and shooting and improve running and jumping skills, as well. You can play with an adjustable hoop in the driveway, or sing up for a community team (which will generally begin between ages 3-5).

T-Ball: Teaches running, balll skills and coordination skills. Using larger balls for young children will help them be successful with catching and throwing.

Yoga: Helps improve flexibility, which is very important since toddlers are growing quickly and develop tight musles quickly. Yoga can also improve strength (especially in the core muscles) and balance. Several toddler yoga videos can be found online, and classes are available throught out the DFW area.

Gymnastics: Another way to gain strength, balance and flexibility, gymnastics is a sport that children can begin learning as early as 18 months old. Many gyms have special toddler and preschool classes, as well as "parent and me" classes.

Yard games: The old staples of "tag" and "hide and seek" are great for teaching turn taking and problem solving, as well as practicing and running and climbing. Taking your child to a local playground also offers a wide variety of ways to practice climbing stairs, running, swinging, balance, etc. 

With all of these, safety is a primary concern. Toddlers are at high risk of injury when practicing new things. Contact your pediatrician if you feel like your child is having difficulty learning new skills and they may refer you for evaluation by a physical therapist to evaluate your child and help them learn these new skills.

About the author

Jodi Burgett PT, DPT, CPST, is the clinical coordinator of Neurodevelopmental Physical Therapy at Cook Children's. Physical therapy at Cook Children's focuses on large motor and functional skils to enhance development, restore function and prevent disability from pediatric conditions, illness or injury. Cook Children's has Rehabilition Services in locations in Fort Worth, Hurst and most recently in Mansfield.

The role of warming up and its impact on performance is debated regularly. Sometimes the coaches of our kids’ sports teams do not find the time to have the athletes perform an appropriate warm up prior to practice. They may not see enough benefit to use precious practice time for warming up. However, participating in sporting activities, practice or competition, without an appropriate warm up can not only decrease performance, but also place the athletes at risk for injury.

Much of the recently published evidence shows that static stretching (i.e. holding positions for set amounts of time) can decrease the muscles ability to respond to the stresses it experiences during activity. Static stretching may be of more benefit post workout or when only focused on increasing muscular length for improved flexibility.

A dynamic warm up or dynamic stretching is a method of warming up in which the athlete moves throughout available range of motion with stretches in a controlled manner. It has many benefits that are not seen with static stretching such as increasing blood flow to the muscles, increasing internal temperature, and preparing muscles for the sport specific movements they will need for the activity. This sort of warm up increases blood flow to the muscles and stretches them through specific motions that will be used while participating in their sport. In addition, most dynamic stretches target large muscle groups or multiple muscle groups together.

To successfully complete a dynamic warm up, athletes should follow some important steps. An appropriate warm up usually takes approximately 15 minutes.

1. Perform light aerobic activity to increase cardiac output and blood flow.

2. Follow with dynamic stretches to stretch muscles that will be needed for participation.

3. Optionally follow up with agility drills as desired. Examples include: butt kicks, high knees, skips, etc.

When performing dynamic stretches, it is important to monitor form and control. If dynamic stretches are performed without appropriate control, muscles can be stretched too far too quickly and pose a threat to injury. If you have an injury or need further guidance, please see a medical professional, such as your primary care physician or pediatrician.

Related articles

• Does your child play one sport?
• Cook Children's Sports Performance Orthopedic Rehab Team Specialists (SPORTS)
• Dynamic stretching
• The basics of sports injury prevention for kids
• Rise of overuse injuries in school-age athletes 
• Top 10 questions parents have about sport injuries
• Young athlete’s injury prevention guide

About the author

Amanda Stukey, PT, DPT, is a physical therapist for the SPORTS program at Cook Children's. Our physicians, therapists, nurses and technologists work exclusively with kids and understand the unique needs of a growing athlete's bones, muscles, body and mind.