Round TablesPublication Exclusive

Panel discusses epidemic of youth sports injuries, role of prevention programs

At Orthopedics Today Hawaii 2015, we convened a special Banyan Tree session to talk about injuries in youth athletes. This is a real problem that all orthopedic surgeons see on a regular basis — one that, I think, is still under-recognized. In this Orthopedics Today Round Table, we highlight the discussion, particularly as it relates to overhead sports, as well as how orthopedic surgeons can play a role in stemming the tide of injuries. We also talk about innovations to help with prevention and treatment, as well as the role of the STOP Sports Injuries and Pitch Smart programs.

Orthopedic surgeons are leaders of musculoskeletal care in their local communities. We need to make a greater effort to establish programs that disperse this valuable information. I encourage all orthopedic surgeons to take an active part in the youth leagues of their local communities. However, if not you exactly, then make primary care physicians and athletic trainers aware of available resources so we can keep children in the game longer, stronger and with fewer injuries.

Anthony A. Romeo, MD
Moderator

Anthony A. Romeo, MD: What do you mean by the fact that there is an epidemic of youth sports injuries?

James R. Andrews, MD: Early on in my career I would only occasionally see a kid in high school with a throwing arm injury. Around 2000, I started noticing that my examining and operating rooms were filling up with young kids with throwing arm injuries. Now, when I see new patients on Monday morning I will go from room to room and there are young 14- to 18 year-old kids with their parents with adult type throwing arm injuries. Particularly prevalent are the elbow injuries with the Tommy Johns ulnar collateral ligament (UCL) sprains of the elbow.

Roundtable Participants

  • Anthony A. Romeo, MD
  • Moderator

  • Anthony A. Romeo, MD
  • Chicago
  • Christopher S. Ahmad, MD
  • Christopher S. Ahmad, MD
  • New York City
  • James R. Andrews, MD
  • James R. Andrews, MD
  • Gulf Breeze, Fla.
  • Nikhil V. Verma, MD
  • Nikhil V. Verma, MD
  • Chicago

Because of this escalation, I have been trying to get the message out that we have been remiss in orthopedic surgery and in sports medicine relative to prevention of injuries in youth sports, particularly baseball. In other words we have been so busy putting Humpty Dumpty back together again, that we have ignored prevention. Prevention should be our number one priority.

Several years ago when I was president of the American Orthopaedic Society of Sports Medicine (AOSSM) we were able to begin a national initiative called the STOP Sports Injury Program. STOP is an acronym for “sports trauma and overuse prevention” in youth sports. Our motto has been to keep these young athletes out of the operating room and on the playing field.

As I stated, I started tracking the throwing arm injuries in youth baseball at the American Sports Medicine Institute (ASMI) in Birmingham and found there was an ever increasing injury rate in youth baseball. From these statistics, we were able to document that there was a five- to seven-fold increase in injuries in youth baseball since 2000. At ASMI, I we have researched the risk factors and devoted a lot of our research initiative to peer review articles on injuries in youth baseball. From this work, we concluded that there was an epidemic of injuries across the board in youth baseball reaching epidemic proportions.

One of the most important things we did was develop and initiate a pitch count with Little League International. I have served on their board of directors and my hat is off to the Little League because their number one priority has been the health and safety related to their young baseball and softball players. The next big step was that Major League Baseball (MLB) has started an initiative called Pitch Smart and Play Ball to educate parents; coaches and players alike relative to what should be done in youth baseball to prevent injuries. The other thing that we have seen develop is an escalation of elbow injuries in professional baseball players. If you look at them closely you can see that their injuries are related back to some minor elbow problem that happened when they were playing youth baseball. This is the first crop of professionals who came along in the last 10 years to 15 years who played year-round youth baseball.

It appears now that all of the youth baseball organizations are getting behind this initiative, which is now being spearheaded by MLB. My hat is off to the MLB for their effort.

Romeo: Dr. Verma and I did some research on labral tears in the shoulder. When I was guiding Bud Selig through our laboratory and he was looking at our cadaver specimens and mechanism of injury, I was surprised to see this commissioner interested in questions about baseball players at the highest level. We talked about the shoulder and he said, “You know, I know that there has been a problem with the elbow, but it seems like when the elbow goes, you guys are able to fix it. That is just not the way it is with the shoulder. You guys have to keep working hard at figuring out this shoulder problem.” I was just impressed with not only his understanding, but also his verbal support of what he would like to do in terms of helping the sport.

Romeo: What does this epidemic mean to you in terms of your practice?

Christopher S. Ahmad, MD: I have had the same experience as Dr. Andrews — there is a huge number of adolescent and even younger kids coming into the office. Why do I see them? I think it is because they want to see the Yankees’ doctor, but also, in New York City, our hospital system has the only pediatric orthopedic hospital. We have a huge pediatric component to what we do, so we attract pediatric patients. I am the director of the Pediatric Adolescent Sports Medicine program there, so young throwers end up coming there.

What do I think is happening? Some incredibly super-specialization is going on, and I have even seen it trickle up to the draft players. Even 8 years ago, when I first started with the Yankees, a high school draft pick had a good-looking elbow on imaging studies. Now, a high school draft pick player looks like he is 30 years old as a free agent, with the amount of ossification and arthritis that has developed. Volume of throwing and stress to the elbow is changing, even in the last few years that I have appreciated.

It used to be only the free agents and college kids would come in with their strengthening and conditioning coaches. Now, high school kids and 13-year-old kids come to see me with their strength and conditioning coaches. They also have mental conditioning coaches at this age. They have everything professional athletes have and then some. The pressure on them to perform is much different than a generation prior, when it was all about having fun. Now, it is about performance. I think super-specialization causes a lot of the epidemic when they strive to be professional athletes when they are really developing athletes.

Romeo: What do treating physicians need to share with youth athletes about how to prevent getting to the OR? How can we help them understand what is going on and give guidelines on the best way to prevent injuries from becoming surgical problems?

Nikhil V. Verma, MD: I think Dr. Andrews was the first one to recognize that this is a volume-of-throwing injury. Unfortunately, what we are seeing today is that kids are participating in these sports not 3 months or 4 months a year, not even 6 months or 9 months a year, but rather 12 months a year. As Chris pointed out, they are engaged in this sport on multiple levels. They are on a high school team, a travel team and throwing showcases. They have a pitching coach, so the overall volume of throwing is markedly increased. Data suggest the greater the volume of throwing leads to a higher the risk of injury. What these initiatives have been designed to do is to provide safe guidelines to help educate patients, coaches, kids and parents about where we see the injury risk significantly increasing. That has to do with the number of months throwing per year. We generally recommend they are out of throwing for somewhere between 2 months to 3 months per year. It is basically trying to reduce the overall volume of throwing that occurs.

Romeo: Dr. Andrews, one of the stories I enjoy is the way you manage these patients and, maybe even more delicately, manage their parents and coaches. Can you explain what you do?

Andrews:  When I see new patients, I have them write down their history and elaborate about the awards they have won, the championships, perfect games, showcases, etc. These are all, of course, risk factors relative to injuries in the younger throwers. I have them put all this information on the blackboard including when they started throwing and how many innings they play each year and I will leave the room and let them finish that information. When I go back into their room, they usually have run out of blackboard space and I will look at the parents and the young thrower and say, “Do you all know why this young player is here?” They really don’t know how to answer my question. Then I will point to the blackboard and at that point, the parents for the first time understand why their young baseball player is in the office seeing me for a throwing arm problem.

As you can see, prevention is an educational process which begins at the grassroots level and that means trying to educate the parents, grandparents, coaches and the players themselves about their risk factors and what they need to do to prevent throwing arm injuries. Basically, if you understand the risk factors, common sense tells you how to prevent the injury in most cases. Of course, not all injuries in youth baseball are preventable. I usually emphasize to the parents that fatigue in youth baseball is the number one risk factor. Fatigue can come in multiple types, including event fatigue, seasonal fatigue and year-round fatigue.

Moderator Anthony A. Romeo, MD, (far left) also asked panelists (left to right) Nikhil V. Verma, MD; Christopher S. Ahmad, MD; and James R. Andrews, MD, about resources for conseling patients on prevention.

Moderator Anthony A. Romeo, MD, (far left) also asked panelists (left to right) Nikhil V. Verma, MD; Christopher S. Ahmad, MD; and James R. Andrews, MD, about resources for conseling patients on prevention..

Image: Houck K, Orthopedics Today

Our research at ASMI has shown if you play with any of these fatigue factors there is a 36 to 1 times risk that a young player can injure his young shoulder or his elbow. That is a 3,600% increase in the risk factors. If parents don’t get the message with that, then they never will.

I have also emphasized how important it is to get this information to the grandparents. I know as a grandparent I am more protective and worried about my grandkids than I was as a parent with my own children. Sometimes the grandparents can help in getting the message across to their children who are the parents and also watch what their grandkids do. As a matter of fact, grandparents may be the key to prevention.

Romeo: How does a program like Pitch Smart and other programs you use in your practice give guidance to not only to patients, family and coaches, but also orthopedic surgeons? How does this work into the type of care we provide youth athletes?

Ahmad: Our goal is to prevent injuries and provide avenues, and the way we do it is through education. The throwing athlete has many features, more than any other athlete, I think, where there is a complementary group of people to assist them — parents, coaches, physical therapists, orthopedic surgeons, and strength and conditioning coaches. There is such a complement of people we can involve in the educational process so they understand the risk factors and then we can start to tackle these.

Pitch Smart is a MLB-endorsed, created avenue to do research and educate communities on the real risk factors. A factor that is most impressive to me is that volume of throwing is becoming clearer, but patients and families do not appreciate the aspect of the pain they are throwing through. They also do not appreciate the whole fatigue issue.

What do I mean by “they do not appreciate pain”? We did research on children who are not influenced by their parents when they complete surveys. We found 80% of kids said they throw with pain regularly, or at least occasionally, and 50% of the time they are encouraged to throw with pain even though they tell their coaches and parents. Pitch Smart and other programs give us an opportunity to educate everyone about risk factors, not playing through pain and volume of throwing — all the factors we believe are involved in this epidemic.

Romeo: What resources are helpful in counseling patients on prevention?

Verma: I think the efforts, whether it is through the specific guidelines of the AOSSM or MLB, can be disseminated to patients to allow them to take some information home so they can understand exactly what we are talking about in terms of volume of pitches, number of pitches per age group, types of pitches, months of throwing per year, innings per season — all the things we start to think about as injury risk. It helps orthopedic surgeons to disseminate data in terms of showing how much or how accelerated injury risk can be if we do not follow the guidelines appropriately.

Fortunately, the hard work has been done for us with the establishment of websites such as Pitch Smart and the STOP Sports Injuries program through the AOSSM. It is just a matter of directing patients, providers, therapists, trainers and coaches to the right areas.

Romeo: Many orthopedic surgeons may say, “We are busy. We have a lot of things to do. We have a lot of things to fix. This should be in the hands of primary care physicians and primary care sports medicine physicians. I am an orthopedic surgeon. I will take care of them when they have a problem.” What are your thoughts on how orthopedic surgeons can lead the team? Why not let primary care sports physicians take care of the issue?

Andrews: No, I completely disagree with your statement. We as sports medicine orthopedic surgeons have a big responsibility to get involved in prevention of injuries in youth sports. Tony, you don’t really believe the above statement do you?

Romeo: Of course not.

Andrews: It is everybody’s responsibility. It is not an "I" situation it is a "we" situation. If we do not take the bull by the horns and have everyone work together in all the disciplines, unfortunately, it will wind up in the lawyers’ hands. It will then become a medical legal problem which is something we certainly don’t want to see happen. If that happens, we are going to have volunteer coaches being sued and that will certainly not be a good situation.

As sports medicine physicians, all of us, including the orthopedic surgeons and the primary care doctors as well as the trainers and sports therapists, have a responsibility to get involved. So let’s handle it ourselves and keep it out of the courts. It has to be done. Obviously, we as orthopedic surgeons have plenty of surgery to do and we should make time and effort for prevention. It should be a number one priority particularly for our young kids. Unfortunately, it is a difficult problem because there are some 25 youth baseball organizations in the United States and they all have different rules and even different distances from the mound to the home plate.

When I first got on the Board of the Little League International, the major concern was to get involved in prevention of injuries in their youth leagues. We were able to show them from our research projects at ASMI that pitch counts were important and they initiated those rules. Initially there was a backlash by other youth leagues. They would tell the parents don’t let your son play for the Little League because when he gets a perfect game and reaches a certain number of pitches, they will take him out. Come play for us.” That has since changed and pitch counts are accepted and used more now among all of the youth leagues.  Hopefully it will become the standard.

Since we initiated the pitch count rules in Little League International, we have been able to show a significant decrease in the injury rates to the throwing arm which we attribute to the lack of fatigue in these young kids.  We need to work on the high school athletic federations in all 50 states to initiate pitch count rules and safety rules which should be uniformed states.

Hopefully with the recommendations and the big voice of MLB to change the rules to create a safe environment for all of our baseball players.

Romeo: A big factor for all sports is overuse or fatigue. Every time athletes throw a baseball, the force generated at the elbow is enough to tear the ligament, so athletes have to be well-balanced and the muscles have to work to protect the ligament. That is where fatigue plays a role. We have some ways to avoid fatigue because we have prevention programs, but not only does the STOP program give guidelines and hooks one into the Little League guidelines we are big proponents of, but it also provides materials that can be used in communities and shared with primary care physicians and athletic trainers. Pitch Smart also allows us to disseminate information through the Elbow and the Shoulder Research Committee.

Romeo: Chris, we do all the right things, but some kids just have persistent pain. What is your go-to, nonoperative treatment plan? We are going to shut them down and make them rest. Is there anything else you think we should be doing?

Ahmad: My approach to that patient in the office is re-establishing expectations, and I do it in a shocking way. These kids come in with their uniforms on, with pain and a torn ligament, yet they seek something that will get them in the game later that day. The first thing that I say is, “Thank goodness we do not have to go to the OR tonight.” So we change things from going to playing a game tonight to “you have a serious problem.” I try to create gravity about it. When I see patients with Little Leaguer’s elbow, I call it a fracture of the apophasis. It is broken. I do not just say it is a little inflamed. I usually try to change the expectation so the gravity is more appreciated.

How do we make it so it is a real injury in these young athletes? I put a brace on them, not because the brace is therapeutic, but it legitimizes the injury to the family and other players on the team. They do not think he is soft. He has a real problem.

We then go through an extended period of rest. Young athletes require more rest than older athletes even though younger athletes heal better. They are adapting and require rest periods to avoid injury that, I think, is different than adult athletes.

So then we get to the “how can we biologically manipulate them”? I do not have all the answers to that yet. I do not think anybody does yet, but I think we are on the verge of learning how platelet-rich plasma (PRP) and stem cells can assist these patients. I have heard arguments to have prophylactic, end-of-season PRP injections so the ligament can recover during rest periods and athletes don’t have to wait until they get injured to use PRP. All kinds of things are on the horizon, and we will learn more in the next few years.

Romeo: What are your thoughts on preventative management and the available treatments related to biology, such as PRP or stem cells? We have been using it in our athletes at times. Do you believe it will be valuable?

Verma: Most of our experiences come from using it at the minor and major league levels. I have not used it extensively in my adolescent athletes, at least to date. It is probably a little bit of a stretch to think we are going to take a ligament that has discontinuities and fix it with a PRP or a stem cell-type injection. Hopefully, we will get to the point where biology or biologic manipulation will allow us to improve outcomes, but to suggest we are at the point now that a single or even multiple injections will help heal or restore an incompetent ligament that operates at failure load when throwing a baseball is probably a little bit of a lie.

Romeo: MLB teams are a $9 billion-per-year industry. They have coaches, trainers, masseuses, chiropractors and injections, yet 60 to 70 baseball pitchers a year are on injured reserve. So every team has injured baseball pitchers, which costs MLB $500 million a year for players who cannot throw a ball for their teams. What should we be doing in terms of research and figuring out how to keep high-level athletes on the field, which hopefully will trickle down to youth athletes?

Andrews: If you take a careful enough history when confronted with a Tommy Johns injury, you will find that 50% to 60% of the professional players first had some elbow problems at age 12, 13, or 14. This is why MLB has gotten behind this problem. It all begins with prevention and keeping them healthy through their younger days so they can have an injury free career as possible as a professional. Until we really get involved with prevention at the youth levels we will continue to see increased injury patterns as these baseball players mature through college and into the pros.

Romeo: The research we are embarking on now seems to be going in the right direction.

Andrews: I think it is a matter of realizing that we have to put our emphasis on prevention at the grassroots levels. We will never be able to prevent injuries completely particularly relative to the UCL of the elbow. It is like the ACL injury of the knee and, unfortunately, when all the risk factors are minimized the injury can still occur. We can certainly decrease the injury though so it is not in epidemic proportions by recognizing the risk factors and by using common sense.

MLB is making a push to emphasize that our young kids need to participate through their “Play Ball” program. They are also utilizing their public service announcements between innings at baseball games on national television to emphasize to parents, grandparents, young players and coaches the importance of prevention. I think MLB will have an opportunity to push this prevention initiative forward.

Romeo: No matter what we do, there are going to be injuries. It recently has been recognized, especially in younger athletes, that maybe not everyone needs reconstruction. Maybe some injuries can be repaired, and maybe that will speed recovery. Are there patients who you might consider a repair and expect a good result? Or does everybody have to get reconstruction and an extended rehabilitation?

Ahmad: That is a great point, and I was thinking of something as we are talking, which I also want to mention. Then, I will talk about primary repair.

We know for patients who come in with their families this is going to be a problem for the child. We are now studying the overzealous parent in the same way alcoholism is studied. The CAGE criteria for alcoholism is how one responds to questions like, “Do you have a drinking problem?” When you ask a child who is with his dad if he has pain in his elbow and the dad has to answer for the kid about the pain in his elbow, then you start to get a higher- level score. If the dad is wearing a hat of the team his kid plays on, then you get a higher level. If the dad is wearing the uniform, then he is over the top. I truly believe parental influence on kids is dramatic.

The second part I was thinking about while we were going around is perceptions of Tommy John surgery in young athletes. We are trying to temper these perceptions, but there is a cavalier attitude in young athletes that if their elbow has to go, it might as well go now. Other perceptions are that they might as well throw through pain because every professional pitcher needs the operation, and, in fact, if they get the operation, then they will likely be able to throw harder. So they think they are going to throw until they get hurt and then, congratulations, they have a real road to professional baseball.

Part of our work with Pitch Smart is to understand and correct the misperceptions. People do not get back to the way they want to after Tommy John surgery. Even though it is an elegant, beautiful, great operation, there are some problems with it.

Can we avoid the Tommy John operation? There is a select population of young athletes who injure their ligaments so it is damaged, but it is different than some older, mature athletes in that the ligament quality is still good. They do not have chronic changes. It is not calcified and thickened. If it is more of an avulsion-type injury, then there are select few young patients who can have a repair of the ligament. That repair can heal quicker than a reconstruction, and it also preserves the opportunity to do a reconstruction later on in life if they need it. I do a handful every year. I do not do a tremendous amount, but there are some surgeons who are enthusiastic about the young patient avulsion-type injuries, or in the setting of the more normal type of ligament that happens to be repaired, they take advantage of the healing characteristics of younger patients.

Andrews: Let me add to that one quick statement about talking to young kids and their parents about nonoperative treatment for UCL injuries. I can sit there in front of the young player and his parents for an hour explaining why they should not have surgery. At that point, I know there is a question that will come up and I will try to get myself prepared to answer it. The question is as follows: Well, Dr. Andrews, if you don’t operate on him now and you let this heal with a nonoperative protocol will it be as good as a normal ligament once it heals?  Will it prevent him from having further trouble down the road??" That is a hard question for me to answer. My answer to myself is that it will not be as good as an uninjured ligament but that is the question they ask you because then they come right back and say, “Well, if we are going to have that problem, then we want it fixed now.” They don’t understand that the reconstruction of the UCL at a young age is not always successful. The myth is that it will make them a better baseball player and that it is 100% successful and obviously that is not true.

Romeo: In MLB, there are so many UCLs done per year. If you survey all the UCLs done in MLB players in the top 40, there is one guy who has done 40% of them. I think his answer is helpful in terms of knowing what we should be doing. Dr. Andrews, can you give us your top three or four points about UCL reconstruction?

Andrews: The first thing I tell them that is so important is they cannot rush the recovery of the Tommy Johns procedure. They must follow a protocol.  We usually let them begin throwing around 4 months sometimes 6 months.  I also tell them not to expect to have a complete recovery in some 9 months. A lot of times it takes longer than that depending on setbacks. By the way, all of these baseball players at any level are much better the second year back than the first year back. During the first year back in regard to competitive baseball, they have to follow a pitch count. It is a step-by-step progression to be safe and successful in their recovery I also tell them about the other myths associated with the Tommy Johns procedure. Our statistics show they do not necessarily throw harder. They may throw harder because of all the rehab they do, particularly in developing greater core strength, and also just natural maturity as an athlete. It does not necessary relate back directly to the surgical procedure itself. We also know from statistics that in the major leagues the players with a Tommy Johns procedure averages 2 miles per hour loss on their fastball. I always tell my athletes there is no way I can make the ligament as good as the good Lord made it.

Romeo: It is an interesting issue, and we have all been approached by athletes who believe if they have the reconstruction, then they will be able to throw harder. They come in wondering if they should have a prophylactic UCL reconstruction. It is a strange mindset to have to deal with that. We have done research, and most people think the street concept is that they are back to the same level by 12 months. But actually, the mean return back to the same level of play, if they get back to that level of play, is much longer than that. It is 15 months or longer. It is hard for young people to understand that period of time. It is a huge part of their life and they are not so aware.

Romeo: Nik, tell us a little bit about the shoulder. We know there is this issue with the arm in an abducted and externally rotated position. If fatigue gets involved, the humerus does not stay centered on the glenoid and things start to break down. Is this also an epidemic in youth athletes? Is it all part of the same problem?

Verma: I do not think we have seen the same epidemic with the shoulder to the same degree we have seen with the elbow in terms of the volume, for example, of the surgical procedures that Dr. Andrews has reported on in the elbow. Maybe he has had a different experience in the shoulder than we have had. But as Dr. Andrews pointed out, the difficulty in taking care of shoulder problems in the overhead-throwing athlete is it is multifactorial. There are a lot of different pathologies or anatomic changes in the shoulder that at some point can be considered adaptive for the throwing shoulder.

Something happens and they now move from an adaptive situation into a pathologic situation, and it is usually not as simple as one torn structure that needs to be repaired. It is generally a multifactorial breakdown that then requires you to try to figure out what is it that we can fix and how can we push them back into that asymptomatic realm. In many cases, we are not simply able to “normalize” the anatomy as simply as we can, even in the elbow situation, by putting in a new ligament.

That is the difficulty you alluded to earlier with Mr. Selig discussing the fact that we do pretty well in terms of our ability to return an elbow back to throwing. It takes a little bit of time, but we do well. We do not always do so well in terms of getting a patient back to throwing after a shoulder operation.

Romeo: The literature suggests that, in the best of hands, we only get two of three pitchers back to throwing if they have a shoulder injury, such as a labral tear. Most of us realize when we went through school that if we only get two of three, then we would not be practicing in the profession. We have to do better. Why is that? Why is the shoulder 66% or right around that number in multiple studies? Is that is all we can get them back to at the same level of play? Why?

Ahmad: What we are seeing is the shoulder is running at the highest extreme, with stress to perform well and it is easy for it to go over the tipping point. It is walking on a fence and everything is perfect until a slight perturbation happens. To get back to that fine line of being able to perform with these stresses Dr. Andrews mentioned today without getting injured is such a fine line that things happen quickly to the shoulder and re-establishing it is much different than the elbow because there are multiple factors involved with the cartilage, labrum, rotator cuff, capsule and their osteologies. So, I completely agree.

The questions we are going to come to for the shoulder are how much throwing is required to develop the adaptive changes and when are adaptive changes appropriate? When born, retroversion of the humerus is 70°. By the time one reaches adulthood, it is 25°. The natural development is to go from big retroversion to less retroversion. But for the throwing athlete, because of the throwing during the growth time period, it does not develop the normal go-to full anteversion. They have retained retroversion. That gives more external rotation and is likely a protective factor so they need to do some throwing. You cannot start throwing when you are 30 years old and be a baseball pitcher.

You start to develop undersurface rotator cuff tears that will probably be adaptive for them and some labral tears. I would say in our organization, we treat every labral tear of a SLAP lesion that is not acute, traumatic-acquired. It is more insidious with throwing, nonoperatively and we have almost the same success with nonoperative treatment as we do with operative treatment, which is sobering. Athletes can exist with a certain amount of pathology we call adaptive.

Our goal as clinicians is to remember that the MRI scans can be misleading. The history and physical exam tell you what is wrong. Jimmy and I have talked on the phone many times, and he has said to me, “Hey, there is so much wrong with this guy’s shoulder. I do not know what to fix.” And I would say the same thing back to him. “A full-thickness rotator cuff tear and anterior labral tear, a SLAP lesion, biceps tendonitis and then he has a Bennett’s lesion on top of it.” He was existing a year ago with probably just a marginal difference from that. It is complicated.

Romeo: Do you think the STOP Sports Injuries and Pitch Smart programs apply to the shoulder just as well as they do to the elbow?

Andrews: Yes, I think the STOP and Pitch Smart programs are really talking about the entire kinetic chain related to throwing a baseball. We are trying to prevent injuries to the throwing arm and that includes the shoulder and the elbow. Remember fatigue is the big factor in these injuries.  When you asked me a while ago about the advice I give to players and parents. The one thing that comes to mind is the following and I quote, “The last thing that you want to do is have your throwing shoulder operated on because it is not always that successful.”

For orthopedists, there is one other thing I would like for them to realize, I see it all the time. A high school player right in the middle of baseball season gets into fatigue for one reason or another and hurts his shoulder. Let’s say he throws too many pitches and feels a pop in his shoulder or all of a sudden the player has acute shoulder pain. He then sees his doctor and within a week an MRI is done with equivocal findings. At that point, the MRI leads the sports doctor into a quick surgical solution. As I have said many times, if you want an excuse to operate on a throwing shoulder get a MRI. In other words, don't be in a hurry with these young players without the normal course of a conservative protocol. The number one reason for surgery is absolutely the failure of conservative treatment. Again, be careful about getting early MRIs because a lot of times they will lead you in the wrong direction.

Romeo: We have enjoyed the hour we have spent with you and I appreciate all your attention. As Dr. Andrews mentioned, MLB is putting a major initiative behind its Pitch Smart program. So as you see with the NFL and their Play 60 program, which encourages children to get out and play 1 hour every day to mitigate the effects of childhood obesity and other health problems, MLB also has seen this injury epidemic among young athletes.

References:

http://m.mlb.com/pitchsmart.

www.stopsportsinjuries.org.

For more information:

Christopher S. Ahmad, MD, can be reached at Columbia University, Center for Shoulder, Elbow and Sports Medicine, 622 W. 168th, New York, NY 10032; email: csa4@columbia.edu.

James R. Andrews, MD, can be reached at the Andrews Institute for Orthopaedics & Sports Medicine, 1040 Gulf Breeze Pkwy., Suite 203, Gulf Breeze, FL 32561; email: info@theandrewsinstitute.com.

Anthony A. Romeo, MD, can be reached at Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 W. Harrison St., Suite 300, Chicago, IL 60612; email: anthony.romeo@rushortho.com.

Nikhil V. Verma, MD, can be reached at Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 W. Harrison St., Suite 300, Chicago, IL 60612; email: nikhil.verma@rushortho.com.

Disclosures: Ahmad reports he receives research support and is a consultant for Arthrex. Andrews is a consultant for Biomet Sports Medicine, Bauerfiend, Theralase and MiMedx; is the medical director for Physiotherapy Associates; is a stockholder for Connective Orthopaedics and Patient Connection; and is a board member for Fast Health Corporation. Romeo reports he receives royalties, is on the speakers bureau and a consultant for Arthrex; does contracted research for Arthrex and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex, Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed. Verma reports he receives research support from Arthrex, Arthrosurface, DJ Orthopaedics, Smith & Nephew, Athletico, ConMed Linvatec, Miomed and Mitek; has stock or stock options in Cymedica, Minivasive and Omeros; is a  paid consultant for Minivasive and Smith & Nephew; receives IP royalties from Smith & Nephew; and receives publishing royalties, financial or material support from Vindico Medical Education.

At Orthopedics Today Hawaii 2015, we convened a special Banyan Tree session to talk about injuries in youth athletes. This is a real problem that all orthopedic surgeons see on a regular basis — one that, I think, is still under-recognized. In this Orthopedics Today Round Table, we highlight the discussion, particularly as it relates to overhead sports, as well as how orthopedic surgeons can play a role in stemming the tide of injuries. We also talk about innovations to help with prevention and treatment, as well as the role of the STOP Sports Injuries and Pitch Smart programs.

Orthopedic surgeons are leaders of musculoskeletal care in their local communities. We need to make a greater effort to establish programs that disperse this valuable information. I encourage all orthopedic surgeons to take an active part in the youth leagues of their local communities. However, if not you exactly, then make primary care physicians and athletic trainers aware of available resources so we can keep children in the game longer, stronger and with fewer injuries.

Anthony A. Romeo, MD
Moderator

Anthony A. Romeo, MD: What do you mean by the fact that there is an epidemic of youth sports injuries?

James R. Andrews, MD: Early on in my career I would only occasionally see a kid in high school with a throwing arm injury. Around 2000, I started noticing that my examining and operating rooms were filling up with young kids with throwing arm injuries. Now, when I see new patients on Monday morning I will go from room to room and there are young 14- to 18 year-old kids with their parents with adult type throwing arm injuries. Particularly prevalent are the elbow injuries with the Tommy Johns ulnar collateral ligament (UCL) sprains of the elbow.

Roundtable Participants

  • Anthony A. Romeo, MD
  • Moderator

  • Anthony A. Romeo, MD
  • Chicago
  • Christopher S. Ahmad, MD
  • Christopher S. Ahmad, MD
  • New York City
  • James R. Andrews, MD
  • James R. Andrews, MD
  • Gulf Breeze, Fla.
  • Nikhil V. Verma, MD
  • Nikhil V. Verma, MD
  • Chicago

Because of this escalation, I have been trying to get the message out that we have been remiss in orthopedic surgery and in sports medicine relative to prevention of injuries in youth sports, particularly baseball. In other words we have been so busy putting Humpty Dumpty back together again, that we have ignored prevention. Prevention should be our number one priority.

Several years ago when I was president of the American Orthopaedic Society of Sports Medicine (AOSSM) we were able to begin a national initiative called the STOP Sports Injury Program. STOP is an acronym for “sports trauma and overuse prevention” in youth sports. Our motto has been to keep these young athletes out of the operating room and on the playing field.

As I stated, I started tracking the throwing arm injuries in youth baseball at the American Sports Medicine Institute (ASMI) in Birmingham and found there was an ever increasing injury rate in youth baseball. From these statistics, we were able to document that there was a five- to seven-fold increase in injuries in youth baseball since 2000. At ASMI, I we have researched the risk factors and devoted a lot of our research initiative to peer review articles on injuries in youth baseball. From this work, we concluded that there was an epidemic of injuries across the board in youth baseball reaching epidemic proportions.

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One of the most important things we did was develop and initiate a pitch count with Little League International. I have served on their board of directors and my hat is off to the Little League because their number one priority has been the health and safety related to their young baseball and softball players. The next big step was that Major League Baseball (MLB) has started an initiative called Pitch Smart and Play Ball to educate parents; coaches and players alike relative to what should be done in youth baseball to prevent injuries. The other thing that we have seen develop is an escalation of elbow injuries in professional baseball players. If you look at them closely you can see that their injuries are related back to some minor elbow problem that happened when they were playing youth baseball. This is the first crop of professionals who came along in the last 10 years to 15 years who played year-round youth baseball.

It appears now that all of the youth baseball organizations are getting behind this initiative, which is now being spearheaded by MLB. My hat is off to the MLB for their effort.

Romeo: Dr. Verma and I did some research on labral tears in the shoulder. When I was guiding Bud Selig through our laboratory and he was looking at our cadaver specimens and mechanism of injury, I was surprised to see this commissioner interested in questions about baseball players at the highest level. We talked about the shoulder and he said, “You know, I know that there has been a problem with the elbow, but it seems like when the elbow goes, you guys are able to fix it. That is just not the way it is with the shoulder. You guys have to keep working hard at figuring out this shoulder problem.” I was just impressed with not only his understanding, but also his verbal support of what he would like to do in terms of helping the sport.

Romeo: What does this epidemic mean to you in terms of your practice?

Christopher S. Ahmad, MD: I have had the same experience as Dr. Andrews — there is a huge number of adolescent and even younger kids coming into the office. Why do I see them? I think it is because they want to see the Yankees’ doctor, but also, in New York City, our hospital system has the only pediatric orthopedic hospital. We have a huge pediatric component to what we do, so we attract pediatric patients. I am the director of the Pediatric Adolescent Sports Medicine program there, so young throwers end up coming there.

What do I think is happening? Some incredibly super-specialization is going on, and I have even seen it trickle up to the draft players. Even 8 years ago, when I first started with the Yankees, a high school draft pick had a good-looking elbow on imaging studies. Now, a high school draft pick player looks like he is 30 years old as a free agent, with the amount of ossification and arthritis that has developed. Volume of throwing and stress to the elbow is changing, even in the last few years that I have appreciated.

It used to be only the free agents and college kids would come in with their strengthening and conditioning coaches. Now, high school kids and 13-year-old kids come to see me with their strength and conditioning coaches. They also have mental conditioning coaches at this age. They have everything professional athletes have and then some. The pressure on them to perform is much different than a generation prior, when it was all about having fun. Now, it is about performance. I think super-specialization causes a lot of the epidemic when they strive to be professional athletes when they are really developing athletes.

Romeo: What do treating physicians need to share with youth athletes about how to prevent getting to the OR? How can we help them understand what is going on and give guidelines on the best way to prevent injuries from becoming surgical problems?

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Nikhil V. Verma, MD: I think Dr. Andrews was the first one to recognize that this is a volume-of-throwing injury. Unfortunately, what we are seeing today is that kids are participating in these sports not 3 months or 4 months a year, not even 6 months or 9 months a year, but rather 12 months a year. As Chris pointed out, they are engaged in this sport on multiple levels. They are on a high school team, a travel team and throwing showcases. They have a pitching coach, so the overall volume of throwing is markedly increased. Data suggest the greater the volume of throwing leads to a higher the risk of injury. What these initiatives have been designed to do is to provide safe guidelines to help educate patients, coaches, kids and parents about where we see the injury risk significantly increasing. That has to do with the number of months throwing per year. We generally recommend they are out of throwing for somewhere between 2 months to 3 months per year. It is basically trying to reduce the overall volume of throwing that occurs.

Romeo: Dr. Andrews, one of the stories I enjoy is the way you manage these patients and, maybe even more delicately, manage their parents and coaches. Can you explain what you do?

Andrews:  When I see new patients, I have them write down their history and elaborate about the awards they have won, the championships, perfect games, showcases, etc. These are all, of course, risk factors relative to injuries in the younger throwers. I have them put all this information on the blackboard including when they started throwing and how many innings they play each year and I will leave the room and let them finish that information. When I go back into their room, they usually have run out of blackboard space and I will look at the parents and the young thrower and say, “Do you all know why this young player is here?” They really don’t know how to answer my question. Then I will point to the blackboard and at that point, the parents for the first time understand why their young baseball player is in the office seeing me for a throwing arm problem.

As you can see, prevention is an educational process which begins at the grassroots level and that means trying to educate the parents, grandparents, coaches and the players themselves about their risk factors and what they need to do to prevent throwing arm injuries. Basically, if you understand the risk factors, common sense tells you how to prevent the injury in most cases. Of course, not all injuries in youth baseball are preventable. I usually emphasize to the parents that fatigue in youth baseball is the number one risk factor. Fatigue can come in multiple types, including event fatigue, seasonal fatigue and year-round fatigue.

Moderator Anthony A. Romeo, MD, (far left) also asked panelists (left to right) Nikhil V. Verma, MD; Christopher S. Ahmad, MD; and James R. Andrews, MD, about resources for conseling patients on prevention.

Moderator Anthony A. Romeo, MD, (far left) also asked panelists (left to right) Nikhil V. Verma, MD; Christopher S. Ahmad, MD; and James R. Andrews, MD, about resources for conseling patients on prevention..

Image: Houck K, Orthopedics Today

Our research at ASMI has shown if you play with any of these fatigue factors there is a 36 to 1 times risk that a young player can injure his young shoulder or his elbow. That is a 3,600% increase in the risk factors. If parents don’t get the message with that, then they never will.

I have also emphasized how important it is to get this information to the grandparents. I know as a grandparent I am more protective and worried about my grandkids than I was as a parent with my own children. Sometimes the grandparents can help in getting the message across to their children who are the parents and also watch what their grandkids do. As a matter of fact, grandparents may be the key to prevention.

Romeo: How does a program like Pitch Smart and other programs you use in your practice give guidance to not only to patients, family and coaches, but also orthopedic surgeons? How does this work into the type of care we provide youth athletes?

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Ahmad: Our goal is to prevent injuries and provide avenues, and the way we do it is through education. The throwing athlete has many features, more than any other athlete, I think, where there is a complementary group of people to assist them — parents, coaches, physical therapists, orthopedic surgeons, and strength and conditioning coaches. There is such a complement of people we can involve in the educational process so they understand the risk factors and then we can start to tackle these.

Pitch Smart is a MLB-endorsed, created avenue to do research and educate communities on the real risk factors. A factor that is most impressive to me is that volume of throwing is becoming clearer, but patients and families do not appreciate the aspect of the pain they are throwing through. They also do not appreciate the whole fatigue issue.

What do I mean by “they do not appreciate pain”? We did research on children who are not influenced by their parents when they complete surveys. We found 80% of kids said they throw with pain regularly, or at least occasionally, and 50% of the time they are encouraged to throw with pain even though they tell their coaches and parents. Pitch Smart and other programs give us an opportunity to educate everyone about risk factors, not playing through pain and volume of throwing — all the factors we believe are involved in this epidemic.

Romeo: What resources are helpful in counseling patients on prevention?

Verma: I think the efforts, whether it is through the specific guidelines of the AOSSM or MLB, can be disseminated to patients to allow them to take some information home so they can understand exactly what we are talking about in terms of volume of pitches, number of pitches per age group, types of pitches, months of throwing per year, innings per season — all the things we start to think about as injury risk. It helps orthopedic surgeons to disseminate data in terms of showing how much or how accelerated injury risk can be if we do not follow the guidelines appropriately.

Fortunately, the hard work has been done for us with the establishment of websites such as Pitch Smart and the STOP Sports Injuries program through the AOSSM. It is just a matter of directing patients, providers, therapists, trainers and coaches to the right areas.

Romeo: Many orthopedic surgeons may say, “We are busy. We have a lot of things to do. We have a lot of things to fix. This should be in the hands of primary care physicians and primary care sports medicine physicians. I am an orthopedic surgeon. I will take care of them when they have a problem.” What are your thoughts on how orthopedic surgeons can lead the team? Why not let primary care sports physicians take care of the issue?

Andrews: No, I completely disagree with your statement. We as sports medicine orthopedic surgeons have a big responsibility to get involved in prevention of injuries in youth sports. Tony, you don’t really believe the above statement do you?

Romeo: Of course not.

Andrews: It is everybody’s responsibility. It is not an "I" situation it is a "we" situation. If we do not take the bull by the horns and have everyone work together in all the disciplines, unfortunately, it will wind up in the lawyers’ hands. It will then become a medical legal problem which is something we certainly don’t want to see happen. If that happens, we are going to have volunteer coaches being sued and that will certainly not be a good situation.

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As sports medicine physicians, all of us, including the orthopedic surgeons and the primary care doctors as well as the trainers and sports therapists, have a responsibility to get involved. So let’s handle it ourselves and keep it out of the courts. It has to be done. Obviously, we as orthopedic surgeons have plenty of surgery to do and we should make time and effort for prevention. It should be a number one priority particularly for our young kids. Unfortunately, it is a difficult problem because there are some 25 youth baseball organizations in the United States and they all have different rules and even different distances from the mound to the home plate.

When I first got on the Board of the Little League International, the major concern was to get involved in prevention of injuries in their youth leagues. We were able to show them from our research projects at ASMI that pitch counts were important and they initiated those rules. Initially there was a backlash by other youth leagues. They would tell the parents don’t let your son play for the Little League because when he gets a perfect game and reaches a certain number of pitches, they will take him out. Come play for us.” That has since changed and pitch counts are accepted and used more now among all of the youth leagues.  Hopefully it will become the standard.

Since we initiated the pitch count rules in Little League International, we have been able to show a significant decrease in the injury rates to the throwing arm which we attribute to the lack of fatigue in these young kids.  We need to work on the high school athletic federations in all 50 states to initiate pitch count rules and safety rules which should be uniformed states.

Hopefully with the recommendations and the big voice of MLB to change the rules to create a safe environment for all of our baseball players.

Romeo: A big factor for all sports is overuse or fatigue. Every time athletes throw a baseball, the force generated at the elbow is enough to tear the ligament, so athletes have to be well-balanced and the muscles have to work to protect the ligament. That is where fatigue plays a role. We have some ways to avoid fatigue because we have prevention programs, but not only does the STOP program give guidelines and hooks one into the Little League guidelines we are big proponents of, but it also provides materials that can be used in communities and shared with primary care physicians and athletic trainers. Pitch Smart also allows us to disseminate information through the Elbow and the Shoulder Research Committee.

Romeo: Chris, we do all the right things, but some kids just have persistent pain. What is your go-to, nonoperative treatment plan? We are going to shut them down and make them rest. Is there anything else you think we should be doing?

Ahmad: My approach to that patient in the office is re-establishing expectations, and I do it in a shocking way. These kids come in with their uniforms on, with pain and a torn ligament, yet they seek something that will get them in the game later that day. The first thing that I say is, “Thank goodness we do not have to go to the OR tonight.” So we change things from going to playing a game tonight to “you have a serious problem.” I try to create gravity about it. When I see patients with Little Leaguer’s elbow, I call it a fracture of the apophasis. It is broken. I do not just say it is a little inflamed. I usually try to change the expectation so the gravity is more appreciated.

How do we make it so it is a real injury in these young athletes? I put a brace on them, not because the brace is therapeutic, but it legitimizes the injury to the family and other players on the team. They do not think he is soft. He has a real problem.

We then go through an extended period of rest. Young athletes require more rest than older athletes even though younger athletes heal better. They are adapting and require rest periods to avoid injury that, I think, is different than adult athletes.

So then we get to the “how can we biologically manipulate them”? I do not have all the answers to that yet. I do not think anybody does yet, but I think we are on the verge of learning how platelet-rich plasma (PRP) and stem cells can assist these patients. I have heard arguments to have prophylactic, end-of-season PRP injections so the ligament can recover during rest periods and athletes don’t have to wait until they get injured to use PRP. All kinds of things are on the horizon, and we will learn more in the next few years.

Romeo: What are your thoughts on preventative management and the available treatments related to biology, such as PRP or stem cells? We have been using it in our athletes at times. Do you believe it will be valuable?

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Verma: Most of our experiences come from using it at the minor and major league levels. I have not used it extensively in my adolescent athletes, at least to date. It is probably a little bit of a stretch to think we are going to take a ligament that has discontinuities and fix it with a PRP or a stem cell-type injection. Hopefully, we will get to the point where biology or biologic manipulation will allow us to improve outcomes, but to suggest we are at the point now that a single or even multiple injections will help heal or restore an incompetent ligament that operates at failure load when throwing a baseball is probably a little bit of a lie.

Romeo: MLB teams are a $9 billion-per-year industry. They have coaches, trainers, masseuses, chiropractors and injections, yet 60 to 70 baseball pitchers a year are on injured reserve. So every team has injured baseball pitchers, which costs MLB $500 million a year for players who cannot throw a ball for their teams. What should we be doing in terms of research and figuring out how to keep high-level athletes on the field, which hopefully will trickle down to youth athletes?

Andrews: If you take a careful enough history when confronted with a Tommy Johns injury, you will find that 50% to 60% of the professional players first had some elbow problems at age 12, 13, or 14. This is why MLB has gotten behind this problem. It all begins with prevention and keeping them healthy through their younger days so they can have an injury free career as possible as a professional. Until we really get involved with prevention at the youth levels we will continue to see increased injury patterns as these baseball players mature through college and into the pros.

Romeo: The research we are embarking on now seems to be going in the right direction.

Andrews: I think it is a matter of realizing that we have to put our emphasis on prevention at the grassroots levels. We will never be able to prevent injuries completely particularly relative to the UCL of the elbow. It is like the ACL injury of the knee and, unfortunately, when all the risk factors are minimized the injury can still occur. We can certainly decrease the injury though so it is not in epidemic proportions by recognizing the risk factors and by using common sense.

MLB is making a push to emphasize that our young kids need to participate through their “Play Ball” program. They are also utilizing their public service announcements between innings at baseball games on national television to emphasize to parents, grandparents, young players and coaches the importance of prevention. I think MLB will have an opportunity to push this prevention initiative forward.

Romeo: No matter what we do, there are going to be injuries. It recently has been recognized, especially in younger athletes, that maybe not everyone needs reconstruction. Maybe some injuries can be repaired, and maybe that will speed recovery. Are there patients who you might consider a repair and expect a good result? Or does everybody have to get reconstruction and an extended rehabilitation?

Ahmad: That is a great point, and I was thinking of something as we are talking, which I also want to mention. Then, I will talk about primary repair.

We know for patients who come in with their families this is going to be a problem for the child. We are now studying the overzealous parent in the same way alcoholism is studied. The CAGE criteria for alcoholism is how one responds to questions like, “Do you have a drinking problem?” When you ask a child who is with his dad if he has pain in his elbow and the dad has to answer for the kid about the pain in his elbow, then you start to get a higher- level score. If the dad is wearing a hat of the team his kid plays on, then you get a higher level. If the dad is wearing the uniform, then he is over the top. I truly believe parental influence on kids is dramatic.

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The second part I was thinking about while we were going around is perceptions of Tommy John surgery in young athletes. We are trying to temper these perceptions, but there is a cavalier attitude in young athletes that if their elbow has to go, it might as well go now. Other perceptions are that they might as well throw through pain because every professional pitcher needs the operation, and, in fact, if they get the operation, then they will likely be able to throw harder. So they think they are going to throw until they get hurt and then, congratulations, they have a real road to professional baseball.

Part of our work with Pitch Smart is to understand and correct the misperceptions. People do not get back to the way they want to after Tommy John surgery. Even though it is an elegant, beautiful, great operation, there are some problems with it.

Can we avoid the Tommy John operation? There is a select population of young athletes who injure their ligaments so it is damaged, but it is different than some older, mature athletes in that the ligament quality is still good. They do not have chronic changes. It is not calcified and thickened. If it is more of an avulsion-type injury, then there are select few young patients who can have a repair of the ligament. That repair can heal quicker than a reconstruction, and it also preserves the opportunity to do a reconstruction later on in life if they need it. I do a handful every year. I do not do a tremendous amount, but there are some surgeons who are enthusiastic about the young patient avulsion-type injuries, or in the setting of the more normal type of ligament that happens to be repaired, they take advantage of the healing characteristics of younger patients.

Andrews: Let me add to that one quick statement about talking to young kids and their parents about nonoperative treatment for UCL injuries. I can sit there in front of the young player and his parents for an hour explaining why they should not have surgery. At that point, I know there is a question that will come up and I will try to get myself prepared to answer it. The question is as follows: Well, Dr. Andrews, if you don’t operate on him now and you let this heal with a nonoperative protocol will it be as good as a normal ligament once it heals?  Will it prevent him from having further trouble down the road??" That is a hard question for me to answer. My answer to myself is that it will not be as good as an uninjured ligament but that is the question they ask you because then they come right back and say, “Well, if we are going to have that problem, then we want it fixed now.” They don’t understand that the reconstruction of the UCL at a young age is not always successful. The myth is that it will make them a better baseball player and that it is 100% successful and obviously that is not true.

Romeo: In MLB, there are so many UCLs done per year. If you survey all the UCLs done in MLB players in the top 40, there is one guy who has done 40% of them. I think his answer is helpful in terms of knowing what we should be doing. Dr. Andrews, can you give us your top three or four points about UCL reconstruction?

Andrews: The first thing I tell them that is so important is they cannot rush the recovery of the Tommy Johns procedure. They must follow a protocol.  We usually let them begin throwing around 4 months sometimes 6 months.  I also tell them not to expect to have a complete recovery in some 9 months. A lot of times it takes longer than that depending on setbacks. By the way, all of these baseball players at any level are much better the second year back than the first year back. During the first year back in regard to competitive baseball, they have to follow a pitch count. It is a step-by-step progression to be safe and successful in their recovery I also tell them about the other myths associated with the Tommy Johns procedure. Our statistics show they do not necessarily throw harder. They may throw harder because of all the rehab they do, particularly in developing greater core strength, and also just natural maturity as an athlete. It does not necessary relate back directly to the surgical procedure itself. We also know from statistics that in the major leagues the players with a Tommy Johns procedure averages 2 miles per hour loss on their fastball. I always tell my athletes there is no way I can make the ligament as good as the good Lord made it.

Romeo: It is an interesting issue, and we have all been approached by athletes who believe if they have the reconstruction, then they will be able to throw harder. They come in wondering if they should have a prophylactic UCL reconstruction. It is a strange mindset to have to deal with that. We have done research, and most people think the street concept is that they are back to the same level by 12 months. But actually, the mean return back to the same level of play, if they get back to that level of play, is much longer than that. It is 15 months or longer. It is hard for young people to understand that period of time. It is a huge part of their life and they are not so aware.

Romeo: Nik, tell us a little bit about the shoulder. We know there is this issue with the arm in an abducted and externally rotated position. If fatigue gets involved, the humerus does not stay centered on the glenoid and things start to break down. Is this also an epidemic in youth athletes? Is it all part of the same problem?

Verma: I do not think we have seen the same epidemic with the shoulder to the same degree we have seen with the elbow in terms of the volume, for example, of the surgical procedures that Dr. Andrews has reported on in the elbow. Maybe he has had a different experience in the shoulder than we have had. But as Dr. Andrews pointed out, the difficulty in taking care of shoulder problems in the overhead-throwing athlete is it is multifactorial. There are a lot of different pathologies or anatomic changes in the shoulder that at some point can be considered adaptive for the throwing shoulder.

Something happens and they now move from an adaptive situation into a pathologic situation, and it is usually not as simple as one torn structure that needs to be repaired. It is generally a multifactorial breakdown that then requires you to try to figure out what is it that we can fix and how can we push them back into that asymptomatic realm. In many cases, we are not simply able to “normalize” the anatomy as simply as we can, even in the elbow situation, by putting in a new ligament.

That is the difficulty you alluded to earlier with Mr. Selig discussing the fact that we do pretty well in terms of our ability to return an elbow back to throwing. It takes a little bit of time, but we do well. We do not always do so well in terms of getting a patient back to throwing after a shoulder operation.

Romeo: The literature suggests that, in the best of hands, we only get two of three pitchers back to throwing if they have a shoulder injury, such as a labral tear. Most of us realize when we went through school that if we only get two of three, then we would not be practicing in the profession. We have to do better. Why is that? Why is the shoulder 66% or right around that number in multiple studies? Is that is all we can get them back to at the same level of play? Why?

Ahmad: What we are seeing is the shoulder is running at the highest extreme, with stress to perform well and it is easy for it to go over the tipping point. It is walking on a fence and everything is perfect until a slight perturbation happens. To get back to that fine line of being able to perform with these stresses Dr. Andrews mentioned today without getting injured is such a fine line that things happen quickly to the shoulder and re-establishing it is much different than the elbow because there are multiple factors involved with the cartilage, labrum, rotator cuff, capsule and their osteologies. So, I completely agree.

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The questions we are going to come to for the shoulder are how much throwing is required to develop the adaptive changes and when are adaptive changes appropriate? When born, retroversion of the humerus is 70°. By the time one reaches adulthood, it is 25°. The natural development is to go from big retroversion to less retroversion. But for the throwing athlete, because of the throwing during the growth time period, it does not develop the normal go-to full anteversion. They have retained retroversion. That gives more external rotation and is likely a protective factor so they need to do some throwing. You cannot start throwing when you are 30 years old and be a baseball pitcher.

You start to develop undersurface rotator cuff tears that will probably be adaptive for them and some labral tears. I would say in our organization, we treat every labral tear of a SLAP lesion that is not acute, traumatic-acquired. It is more insidious with throwing, nonoperatively and we have almost the same success with nonoperative treatment as we do with operative treatment, which is sobering. Athletes can exist with a certain amount of pathology we call adaptive.

Our goal as clinicians is to remember that the MRI scans can be misleading. The history and physical exam tell you what is wrong. Jimmy and I have talked on the phone many times, and he has said to me, “Hey, there is so much wrong with this guy’s shoulder. I do not know what to fix.” And I would say the same thing back to him. “A full-thickness rotator cuff tear and anterior labral tear, a SLAP lesion, biceps tendonitis and then he has a Bennett’s lesion on top of it.” He was existing a year ago with probably just a marginal difference from that. It is complicated.

Romeo: Do you think the STOP Sports Injuries and Pitch Smart programs apply to the shoulder just as well as they do to the elbow?

Andrews: Yes, I think the STOP and Pitch Smart programs are really talking about the entire kinetic chain related to throwing a baseball. We are trying to prevent injuries to the throwing arm and that includes the shoulder and the elbow. Remember fatigue is the big factor in these injuries.  When you asked me a while ago about the advice I give to players and parents. The one thing that comes to mind is the following and I quote, “The last thing that you want to do is have your throwing shoulder operated on because it is not always that successful.”

For orthopedists, there is one other thing I would like for them to realize, I see it all the time. A high school player right in the middle of baseball season gets into fatigue for one reason or another and hurts his shoulder. Let’s say he throws too many pitches and feels a pop in his shoulder or all of a sudden the player has acute shoulder pain. He then sees his doctor and within a week an MRI is done with equivocal findings. At that point, the MRI leads the sports doctor into a quick surgical solution. As I have said many times, if you want an excuse to operate on a throwing shoulder get a MRI. In other words, don't be in a hurry with these young players without the normal course of a conservative protocol. The number one reason for surgery is absolutely the failure of conservative treatment. Again, be careful about getting early MRIs because a lot of times they will lead you in the wrong direction.

Romeo: We have enjoyed the hour we have spent with you and I appreciate all your attention. As Dr. Andrews mentioned, MLB is putting a major initiative behind its Pitch Smart program. So as you see with the NFL and their Play 60 program, which encourages children to get out and play 1 hour every day to mitigate the effects of childhood obesity and other health problems, MLB also has seen this injury epidemic among young athletes.

References:

http://m.mlb.com/pitchsmart.

www.stopsportsinjuries.org.

For more information:

Christopher S. Ahmad, MD, can be reached at Columbia University, Center for Shoulder, Elbow and Sports Medicine, 622 W. 168th, New York, NY 10032; email: csa4@columbia.edu.

James R. Andrews, MD, can be reached at the Andrews Institute for Orthopaedics & Sports Medicine, 1040 Gulf Breeze Pkwy., Suite 203, Gulf Breeze, FL 32561; email: info@theandrewsinstitute.com.

Anthony A. Romeo, MD, can be reached at Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 W. Harrison St., Suite 300, Chicago, IL 60612; email: anthony.romeo@rushortho.com.

Nikhil V. Verma, MD, can be reached at Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 W. Harrison St., Suite 300, Chicago, IL 60612; email: nikhil.verma@rushortho.com.

Disclosures: Ahmad reports he receives research support and is a consultant for Arthrex. Andrews is a consultant for Biomet Sports Medicine, Bauerfiend, Theralase and MiMedx; is the medical director for Physiotherapy Associates; is a stockholder for Connective Orthopaedics and Patient Connection; and is a board member for Fast Health Corporation. Romeo reports he receives royalties, is on the speakers bureau and a consultant for Arthrex; does contracted research for Arthrex and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex, Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed. Verma reports he receives research support from Arthrex, Arthrosurface, DJ Orthopaedics, Smith & Nephew, Athletico, ConMed Linvatec, Miomed and Mitek; has stock or stock options in Cymedica, Minivasive and Omeros; is a  paid consultant for Minivasive and Smith & Nephew; receives IP royalties from Smith & Nephew; and receives publishing royalties, financial or material support from Vindico Medical Education.