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.

Pointing Out the Top 10 Pediatric Sports Musculoskeletal Injuries

The Top 10 Sports Musculoskeletal Sports Injury list is a ranking that I'm guessing most athletes don't want to make, and most parents don't want to miss.

How to best know if you belong on this list?

Trust your finger tips.

Speaking at the 2016 American Academy of Pediatrics National Convention and Exhibition, I was asked along with good friend and colleague Hank Chambers to share insight on identifying and managing the Top 10 Pediatric Sports Musculoskeletal Injuries with a Case-Based Review.

Our Top 10 aptly started at the top of the body (neck) and ran down to the bottom (foot/ankle) with several injuries in between.

We looked at:

• stingers
• shoulder pain
• elbow injuries
• wrist injuries
•  low back pain
• hamstring avulsion injuries
•  acute knee injuries
•  shin pain
• ankle sprains
• heel pain in growing children.

Some were fairly serious and activity threatening, others were more of a nuisance.

A pretty diverse offering of injuries, so one would tend to think that there would be little that actually brings them together.

However, for those listening to the talk, they heard us mention a similar refrain over and over again.

The value of your finger tip.

In helping to determine a type of pain that merits medical attention in the first place, and helps sort out the particular diagnosis, the more localized the pain, the greater the potential concern.

For example,. if a child is reporting pain in the lower leg and uses a wave of the hand to indicate that the discomfort runs along the entire inner shin, then there is one level of concern.

However, if that same child takes the tip of their index finger and points directly and emphatically to a single spot on the inside of the shin bone, my concern is amped up several degrees.

While none of us have x-ray vision, that finding of finger-tip pain is a pretty good surrogate and does tend to correlate with a higher potential of a bone injury, be it a fracture, stress injury, or damage to a apophysis where a tendon attaches to a bone growth region.

So, no matter the body part, from elbow to wrist to foot or ankle, if any young athlete opts to use a finger tip to identify their pain, then use your finger tips to dial up your sports medicine specialist and seek out immediate and appropriate evaluation.

Three Sports Medicine Articles Co-Edited by Dr Koutures in January, 2016 Pediatric Annals

Pleased to see publication of three outstanding articles on Reducing Cumulative Arm Overuse Injuries in Young Throwers, En Pointe Readiness, and EKG Screening in Athletes for the January, 2016 edition of Pediatric Annals. This Sports Medicine themed edition is the first of a 2 part series, with the second set of articles running in February, 2016.

Some of the following content may require a subscription to Pediatric Annals for full access.

Click here to access my Guest Editorial co-written by trusted friend and colleague Valarie Wong, MD

The discipline of pediatric sports medicine deals not just with musculoskeletal care, but rather encompasses a host of medical and orthopedic concerns to optimize safe and lifelong participation in sports and activities. Pediatric health care providers' well-known general medical and anticipatory guidance skills absolutely make them a natural and trusted part of the sports medicine team.

lick here to access the article: Reducing Cumulative Arm Overuse Injuries in Young Throwers by John Schlechter, DO

Overuse injuries are preventable when underlying contributors (GIRD, scapula dyskinesis) are addressed and enforced pitch counts are consistent with recommended limits. The single most important and modifiable risk factor in preventing injury in young throwers is activity modification and adequate rest periods prior to the onset of arm pain.

Click here to access the article: Assessing Readiness for En Pointe in Young Ballet Dancers by Jeffrey Lai, MD and David Kruse, MD

As with any medical evaluation, a proper history and physical examination are the first steps in assessing readiness for dancing en pointe. Age, years of dance training, and hours per week of training are important details to collect during the history, as are the ballerina's dance aspirations. Prior injuries, especially to the lumbar spine, hips, knees, feet, and ankles, should be recorded. The physical examination focuses on anatomy and flexibility, whereas functional assessments of technique, strength, and postural control also help determine pointe readiness

Click here to access the article: Use of Electrocardiogram as Part of the Preparticipation  Exam by Kelly Chain, MD and Andrew Gregory, MD

Sudden cardiac death (SCD) is the leading cause of death in young athletes during sports participation. During preparticipation evaluation (PPE) visits, clinicians are receiving more questions about incorporating electrocardiogram (EKG) screening to detect potentially lethal heart conditions. Many families are aware that several countries in Europe routinely use EKG screening and wonder why the United States has not instituted this recommendation. What are the pros and cons of preparticipation EKG screening in the US, and how might athlete-specific criteria assist in reviewing EKGs conducted in young athletes?

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.

Protecting Adolescent Pitchers

If you happen to know an adolescent pitcher who has the fortune of being taller or throwing harder than his peers, chances are that he is perceived as a valuable asset on the diamond.  Often this attention and demand may lead to requests to play on  multiple teams at the same time.

Unfortunately, these unique characteristics may also lead to an increased risk of shoulder and elbow injuries that could derail the promise of future enjoyment of  baseball. 

A video analysis of 420 adolescent baseball players along with review of pitching and injury histories found that for each 10-inch increase in a pitcher's height, 10 mile-per-hour increase in pitch velocity, or play for more than one team all significantly increased the risk of arm or shoulder injuries.

Does this mean that having a gun for an arm is a bad thing? Is being tall a negative in the injury world?

I think the reality is that anything that makes a young thrower stand out from peers leads to the temptation of overload and the resultant overuse arm and shoulder injuries. 

If proper perspective and patience is exercised, then less chance for badness down the road. However, if combination of all those talents mean requests for more appearances on the mound, playing for more than one team, and thus less overall rest periods, then that is when  the problems begin.

It is a natural to want to showcase talents, but for those who are blessed with certain gifts, ensuring appropriate rest during key developmental years can ward off those unwanted outcomes and lead to more enjoyment down the road.

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