At Cook Children’s SPORTS Rehab, we’ve noticed a shift in what we see in our clinic. Over the past decade, the three major changes we’ve seen are the number of overuse injuries, the amount of early sports specialization and the way we treat concussions.

The first two issues I mentioned go hand-in-hand. It’s no coincidence that we are seeing more overuse injuries at the same time we are seeing early sports specialization. Overuse injuries come from repetitive micro-trauma to tendons, bones, and joints caused by repeating the same type of activity over and over.

If kids are playing the same sport all year around they are repeating the same movement patterns over and over again. Growing up in the 1980s and 1990s there wasn’t the opportunity to play year round sports like there is now. You may have had a favorite sport, but you had to wait for that season to roll around, and in the mean time you would play another sport if you wanted to stay active.

Now, if your favorite sport is baseball, you can find leagues to play in all year round, and the same is true for most other sports. As a result of this early specialization, we are seeing more and more overuse injuries in our young athletes.

In our baseball and softball players we are seeing more elbow and shoulder injuries, and the number one risk factor for overuse injuries of the shoulder and elbow is the volume of throws. If an athlete is playing baseball year round, the volume of throws is going to be significantly greater than an athlete that takes a break to play another sport.

A recent study showed that 15-19 year olds accounted for 56.7 percent of the ulnar collateral ligament reconstructions (Tommy John) performed between 2007-2011.This means over half of these surgeries are being performed on patients who haven’t even finished their freshman year of college. While early specialization is a contributor to the uptick in these overuse injuries it is not the only factor. Things like poor mechanics, poor flexibility and inadequate strength all contribute to overuse injuries. As more and more kids participate in athletics there becomes more and more need for good conditioning and injury prevention programs. Increased sports participation is a great problem to have, because that means our kids are being active, but it also increases the need for our coaches, and we as parents, to be more aware of ways to keep our kids safe from these overuse injuries.

Treatment of concussion has been a popular topic in the news as of late, and this is an area that has changed significantly over the last decade and continues to evolve as we learn more about these injuries. Ten years ago we tried to grade concussions based on the severity. The concussions were graded 1-3 based on the patient’s symptoms and whether they lost consciousness. In some cases of Grade 1 concussions, the athlete was allowed to return to activities the same day as the injury.

We then switched to saying the athlete either has a concussion or they don’t, and all athletes that were deemed to have a concussion were disqualified from participation until cleared by a physician. In most cases we would shut these athletes down completely; limiting TV, school, phone time and interaction with other people in an attempt to let them get complete cognitive rest until their symptoms resolved. Then once symptoms resolved we would start a return to school and return to play protocol.

Now kids still have to be cleared by a physician, and they still have to follow a return to play protocol, but we have realized that completely isolating these kids while they recover and limiting their interaction with friends was doing more harm than good.

So after a brief period of brain rest (approximately three days), we start slowly integrating kids back into activities of daily life as tolerated. It is important to have a physician that deals with concussions involved in the patients return to activity so that they are getting the appropriate accommodations at school and home to allow for the appropriate amount of rest, but that will still allow enough activity to stimulate the patient enough to promote recovery and keep them from becoming isolated.

For more on the specifics of how treatments have changed for all of these areas, and for information on other changes in sports medicine, we would love for you to attend our annual Cook Children’s Sports Medicine Symposium July 21, 2016.

SPORTS Symposium

Education is the key to keeping our young female athletes in their sport vs. being on the sideline with an injury. To learn more Cook Children’s has an annualSPORTS Symposium to educate those who work with our athletes: Coaches, athletic trainers, physical therapists and school nurses.

Please join us on July 21, 2016, to learn more about the female athlete in the morning and what is sending athletes to the ER in the afternoon.

Click here to register and attend the event. Click here to register for the Web cast.

Early Bird Special Ends June 30, 2016

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