Chris G. Koutures, MD, FAAP Pediatric and sports medicine specialist

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Comprehensive blend of general pediatric and sport medicine care with an individualized approach that enhances the health and knowledge of patients and their families



Proud physician:
USA Volleyball Mens/Womens National Teams
CS Fullerton Intercollegiate Athletics
Chapman University Dance Department
Orange Lutheran High School

Co-Author of Acclaimed Textbook

Pediatric Sports Medicine: Essentials for Office Evaluation

Orange County Physician Of Excellence, 2015 and 2016


Filtering by Tag: little league elbow

Seven Tips to Protect the Arms, Knees and Careers of Young Catchers

There is a great demand for willing and talented catchers, and many great demands are placed especially on the shoulders, elbows, and knees of those who toil behind the plate.

From bullpen warm-ups to bunt defense to gunning out runners at second or third, catchers are a focal point of both practices and games.

All while doing the routine return throwing of the ball to the pitcher with most of this work done in the squat position with foul balls coming right at them.

In all, no player makes more total throws than a catcher.

Yes, the majority of those are fairly easy tosses back to the pitcher.

However, there are those harder pick-offs or throws to catch steals that only add to the cumulative stress.

And when pitchers get tired, they get replaced- unlike the catcher who tends to stay out there even for both ends of a doubleheader.

While there are pitch count limits and required rest days for pitchers, the only such formal guidelines placed on catchers are by Little League Baseball which mandates that any player who throws more than 41 pitches in a game cannot move to catcher in the same game.

So what other guidelines can help protect the overall health and longevity of catchers?

1. Have catchers alternate standing and being in the squat position with return tosses to the pitcher.

  • Throwing from the squat is quicker and looks pretty cool, but the lack of lower body involvement in the throw places more stress on the shoulder. Coming out of the squat not only gets the legs involved in the throw but also reduces lower leg cramping.

2. Have catchers sit on a bucket for practice and bullpen sessions- allows them to give a consistent target while putting less deep squat-induced pressure on the lower legs. The "knee saver" products are designed in theory to similarly reduce deep knee bending in the squat position.

3. Try to limit unnecessary throwing during practices or bullpen sessions. Let catchers roll balls back or drop them in a bucket- less throwing means less overall stress and likely better throws when they matter.

4. Have a regular rotation of catchers. While inning counts or throw counts like for pitchers do not exist, monitor catchers for signs of fatigue such as slower to come out of squat, weaker throws back to pitchers or to bases, and giving a lower target due to shoulder fatigue. Better even to plan ahead with catcher substitutions rather than waiting for more obvious signs of overload.

5. Select sensible alternate positions- first base is attractive as there is a limited throw demand which then allows some arm rest, and also takes advantage of the fact that most catchers are taller and used to providing good targets for balls coming at them.

6. Caution with the pitcher-catcher combination that results in too many throws and increases the risk of injury.

7. Limit seasonal or annual arm overuse. Catchers playing for more than one team or not taking at least 2-3 months a year off from throwing are at higher risk of shoulder or elbow injuries.


When Can Kids Throw a Curveball?

Want to ignite baseball passions perhaps even more than a Yankee-Red Sox or Dodger-Giant rivalry?

Ask the question “When should young pitchers throw a curveball?” and then stand back.

The basic concern is that the still developing bone and soft tissue structures in the shoulder and elbow may not be able to adequately handle the rotational forces needed to throw a curveball. A wicked curveball thrown early in a career could potentially lead to wicked damage and early termination of said pitching career.

Do scientific studies and articles offer any substantial help?

The USA Baseball Medical and Safety Advisory Committee has the recommendation that a curveball should not be thrown until age 14, with only fastballs and change-ups thrown before this age.

Why age 14? Most likely because most pitchers at this age have nearly full if not complete maturity of growth centers around the elbow and shoulder and thus these joints can better handle the forces of throwing a curveball.

  • Now, not every child develops at the same point, and in pediatrics we are often trained not to use an absolute age to determine maturity, but rather to use certain milestone to better gauge individual development.
  • A pretty solid (and simple) recommendation that maintain this spirit comes from a Major League team physician who states “Don’t throw breaking pitches until you nave shaved".
  • The age or development-based recommendations are primarily based on baseball expert opinion and have no significant evidence-based supporting data.

On the other hand, a systemic review of published studies by Grantham et. al in Sports Health concluded that limited biomechanical and most epidemiologic data do not indicate an increased risk of injury when compared with the fastball in pitchers from Little League through professional ranks.

  • The epidemiologic evidence to support limitations on the curveball is lacking rigor in study design
  • The current biomechanical evidence (kinematic and kinetic analysis of the torso, shoulder, elbow and wrist) does not support limiting the use of curveballs at any level of baseball

         However, before one rushes off to the local diamond to teach the curveball to young throwers, I must share some other important conclusions:

  • A young pitcher has a wicked curveball very likely will be perceived as a better pitcher and thus be asked to throw more often, leading to higher pitch counts which have been shown to contribute to  arm overuse injuries.

o   In my experience, anything that makes a young pitcher stand out (taller than peers, good control, stronger fastball) put more pressure on coaches and families to protect those talents and not let them be overused at too young an age.

  • The “over the top” wrist snap motion routinely used to increase curveball spin may overload certain forearm supinator muscles, so training these muscle groups along with the shoulder rotator cuff muscles for the curveball.

o   Share this opinion, and would also recommend addressing any limitations in shoulder internal rotation range of motion that can also overload the elbow and wrist regions.

  •  Do not underestimate the often unsung virtues of the change-up pitch. The authors found two studies found that throwing a changeup pitch reduced the incidence of elbow and/or shoulder pain and voiced support for USA Baseball’s recommendations to use the change-up to prevent arm injuries.

My bottom line: use stage of development, not simple a specific age, to help determine when a child is ready to throw the curveball. Realize that a good curveball sets a kid up for being asked to pitch more frequently, which can lead to overuse. Assessing shoulder, elbow, and arm strength and range of motion can reduce risk of injury when throwing a curveball.

Getting Safety Info to Those in Need - Are We Best Protecting Young Arms?

The pediatric sports medicine community has diligently produced statements about common injuries and prevention/treatment strategies. We'd like to think that these recommendations are making their way to the playing fields to benefit coaches, parents and players. This is the first in a series of blog posts addressing the current realities of translating safety policy into actual practice. I welcome thoughts and suggestions on how to best perform this key role.

I've had the pleasure of coaching my young twin sons in baseball over the past two seasons, and like many coaches I constantly wonder about how well I am doing with teaching the basics and strategies of this great sport.

Put me in my pediatric sports medicine specialist role, and once again, I am constantly wondering about how well we in the injury prevention community are doing with teaching the basics of injury prevention and translating our knowledge to fellow coaches, parents, and ultimately, to our players.

Let's take the case of arm injuries in young pitchers as an example.

After the realization that too much throwing over the course of a single season and through an entire year both increase the risk of elbow and shoulder injuries in young pitchers, well-researched Pitch Count Recommendations in Young Pitchers were developed and promoted by many sports medicine groups and youth baseball organizations. These guidelines included not allowing young pitchers to throw with any aspect of shoulder or elbow pain.

So, with these great recommendations discussed in lecture halls, outlined on websites, and passed out on brochures and handouts, how are they actually playing out on the diamonds?

Based on the results of two recent studies, those efforts appear to be mostly striking out.

Allison Gilmore, MD and colleagues from Case Western University in Cleveland, OH presented some unique findings from a recent study indicating that pitch count recommendations are not routinely utilized by Little League coaches or parents.

  • 100% of the 61 studied coaches were aware of the pitch count recommendations and did limit pitches thrown by players in some way, and 92% of the coaches knew that arm fatigue was a risk factor for future injury
  • However, when asked about actual implementation of pitch counts to address injury concerns, 44% did not use pitch counts on a regular basis
  • Less than 10% of coaches regularly monitored and set safe limits for amount of pitching over the course of a year, and 41% reported having players who were at-risk for arm injuries due to playing on more than one baseball team during a particular season. These findings probably fall at least equally on the shoulders of parents who allow the year-round or multiple team participation.

  • The apparent acute impact of this lack of compliance? More than 1/3 of coaches had a player unable to play due to an overuse injury.

  • Reasons cited for not following the recommendations?
    • Lack of knowledge
    • Lack of staff to track pitch counts
    • Lack of desire to want to do what was viewed as a tedious task

These results echo those of 2012 study on Knowledge and Compliance With Pitch Count Recommendations: A Survey of Youth Baseball Coaches which had 228 Little League (age 9-15) coaches complete an 18 question survey testing knowledge of pitch count recommendations that indicated:

  • Only 43% of questions were correctly answered
  • 73% reported following pitch count recommendations
  • 53% of coaches felt that other coaches in same league followed the recommendations
  • 35% stated that their pitchers reported shoulder and elbow pain during the season, with 19% reporting one of their pitchers threw with a sore or fatigued arm during the season.

Significant conclusions included concerns over difficulties of coaches following unfamiliar recommendations and potential of greater enforcement efforts by leagues.

As I mull over the findings of these studies, I struggle with the apparent gap between policy and practice and how to best bridge the gap.

Perhaps we in the sports medicine field are the victims of outstanding results of our surgical and rehabilitative efforts? The growing list of pitchers returning to star on the field after potentially career-threatening arm injuries may give an elevated or almost false hope that injury prevention is less important because amazing treatment results are readily available.

Perhaps its because as parents and coaches we still hang on to the adolescent vibe of invincibility- that nothing bad will happen to our kids.

Perhaps the teachers haven't found out the optimal ways to best reach and teach. Is it social media, videos, 1:1 tutorials, high profile pleas?

For now, the wondering will go on.

Preventing Elbow Injuries- There's (soon to be) an App for That.

Be on the lookout for the Throw Like a Pro App designed by the noted duo of orthopedic sports surgeon James Andrews and physical therapist Kevin Wilk. To be released in the next few weeks, it is designed not only to monitor pitch counts, but also to educate players, parents, and coaches about how to prevent elbow injuries.