Jessica Oliva, MS, OTR/L
Virtual Hand to Shoulder Fellow 2023
I have been a pediatric OT for 11 years and have seen my fair share of spinal cord injuries and other (at times) preventable diagnoses. However, nothing scares me more than when my own children participate in potentially dangerous activities (aka my 5-year-old, non-gymnast, daughter attempting to flip into the pool off a diving board).
My son is 8, almost 9 years old, and started playing travel baseball last Fall. Baseball is life in our house…already. When the Yankees aren’t on, he’s watching any team he can find. And of course, to add to my motherly anxiety, pitching is what he loves the most. My whip-smart, left-handed fastball thrower is his team's most reliable, accurate pitcher. He gets thrown in for every playoff or championship game, leaving my stomach in knots. My husband is the head coach, so naturally, I nag him incessantly about watching the “pitch count”. The last thing we need is an injury, before his “baseball career” even begins. So, I started to research. How much evidence can I throw at the coach, aka my husband, to keep our son safe while pitching for years to come?
It all comes down to a few basic guidelines: limiting the pitch count, resting appropriately in between games, and following proper body mechanics in order to protect the shoulder girdle (and more distal joints). Taking one season off from throwing each year is also recommended. When coaches and their pitchers follow proper pitching mechanics while adhering to the current Little League guidelines, injury, such as Little League Shoulder, is preventable. The guidelines are as follows:
Age/Pitch Count per day:
· 6-8 years, 50 pitches
· 9-10 years, 75 pitches
· 11-12 years, 85 pitches
· 13-16 years, 95 pitches
Baseball pitchers league age 14 and under:
NOTE 1: Under no circumstance shall a player pitch in three (3) consecutive days.
NOTE 2: A pitcher’s pitch count for the purposes of the day(s) rest threshold is determined by the first pitch thrown to a batter.
Let’s take a step back.
What is Little League Shoulder?
This physeal injury of the shoulder, proximal humeral epiphysiolysis, is a common throwing injury in children and adolescents. The immature bone and developing soft tissue are significantly stressed by the repetitive throwing motion. The cartilage at the physeal (growth plate) is weak, the soft tissue structures are lax, and neuromuscular movement patterns are poorly developed. In addition, the epiphyseal plates do not typically close until around 20-22 years of age.
In 99% of participants in a meta-analytic study, widening of the proximal humeral physis of the throwing arm was noted. Impairments can include decreased shoulder range of motion and muscle performance and poor neuromuscular control of the scapula, core, and lower extremity.
There are five phases of pitching motion: wind-up, early cocking, late cocking, acceleration, and follow-through. The late cocking and follow-through phases place the greatest forces on the shoulder joint.
· Late Cocking: The arm is in extreme external rotation behind the body, forcing the head of the humerus anteriorly, stressing the ligaments.
· Follow-through: Following rapid internal rotation to release the ball, significant stress is placed on the ligaments and tendons to decelerate/control the humeral head.
What is the recommended treatment?
That is the conclusion that multiple doctors across the country have determined. Two to four months of complete rest from throwing, to be exact. Some rehabilitative programs include:
· Initial phase: joint mobilizations and gentle ROM
· Phase two: includes restoring functional ROM, strengthening and endurance to the scapular, core, and lower extremity muscle groups.
· Phase three: involves pain-free sport-specific strength and endurance exercises. This might include plyometric drills, advanced core control, and lower extremity balance.
· Phase four: focuses on sport-specific drills and reintegration into the sport.
Following a full recovery, it is recommended that pitchers avoid throwing during episodes of pain or fatigue. Also, avoid year-round participation, with several periods of rest throughout. On a positive note, in all cases, the pitchers went back to their normal activities. Once a decrease in physeal widening of the affected humerus was seen, they were considered healed. Key clinical outcomes include symptom resolution, asymptomatic return to activity, and full ROM. In the meta-analytic study, 100% of participants had symptom resolution.
Back to my little pitcher. What does this mean for the coach’s son? We will be closely adhering to any guidelines to keep him safe. As well as taking it easy before games, and icing/resting after games. It puts my mind at ease, knowing significant injury can be prevented. I can be less anxious, knowing my husband will be supporting him in every way possible, on and off the field.
Bednar, E.D., Kay, J., Memon, M., Simunovic, N., Purcell, L., Ayeni, O.R. (2021). Diagnosis and management of little league shoulder: A systematic review. The Orthopaedic Journal of Sports Medicine, 9 (7), 1-15.
Shanley, E. & Thigpen, C. (2013). Throwing injuries in the adolescent athlete. The International Journal of Sports Physical Therapy, 8 (5), 630-640.
Shoulder Injuries in the Throwing Athlete. (2021, August). Ortho Info. American Academy of Orthopaedic Surgeons. Retrieved July 2, 2023. https://orthoinfo.aaos.org/en/diseases--conditions/shoulder-injuries-in-the-throwing-athlete/
Wasylynko, D. (2015). Chronic pain due to little leaguer’s shoulder in an adolescent baseball pitcher: a case report. Journal of the Canadian Chiropractic Association, 59 (4), 383-389.