Elbow Injuries in Young Athletes Throwing a BaseballAbstractThe purpose of this study is to explore some of the most common injuries in young baseball pitchers, how it occurs, risk factors, rehab process, and the stages of how to properly throw to be able to prevent future athletes from injury. This study pursues to answer the research question, why do elbow injuries occur so often in many young baseball athletes. The goal of the study is to find what causes the problem of elbow injuries, and how we can improve athletes in the future. IntroductionIn the past 25 years so many pitchers in baseball, as well as position players, have had elbow issues because of the inadequate knowledge of how to take care of their arms (Wong, Lin, Ayyala, & Kazam, 2017). Young athletes are having pain at a substantial rate which is a reason to worry about the health of each athlete and their threat to injury throwing a baseball. The problem is that kids are having pain at such a young age due to many different variables, and no athlete at such a young age should be throwing with such pain or injuries. For example, kids now aren’t looking at their mechanics of throwing the baseball or keeping up with pitch count instead they are worried about their performance when in the end their performance decreases (Fleisig & Andrews, 2012). If parents and the young players are more educated on this issue of the injury, then it could possibly occur less. According to Fleisig and Andrews (2012), five percent of youth pitchers suffer a serious elbow or shoulder injury (requiring surgery or retirement from baseball) within 10 years. Elbow injuries are common and can happen quickly. Five percent is important when considering the millions of kids playing baseball. Matsuura, Suzue, Kashiwaguchi, Arisawa, Yasui (2013) discovered that 30% of youth baseball players each year have elbow pain. With all the knowledge and technology we have today, future athletes should be able to prevent these injuries at a younger age than previous ones, and the number of athletes injured should drop.Review of LiteratureThe elbow is important in throwing a baseball, and in everyday life (Oshlag & Ray, 2016). Our elbow is essential for us when we use it for simple things throughout our lives, because without it we couldn’t get a lot done; for example, being able to eat your food at the table you have to be able to bend and move your elbow around in order to eat (Oosterwijk, Nieuwenhuis, Schouten, Schans, & Mouton 2018). No elbow equals no range of motion for us (Oosterwijk, et al. 2018). In baseball, it is important because we have to have a rotational axis to launch the ball forward in the proper way so that we can get the best results and perform well (Oosterwijk, et al. 2018). In the end, the elbow is a key factor in our lives and in throwing a baseball so it is definitely a major issue if it is always having problems.Most Common Types of Injuries & How They OccurWong, Lin, Ayyala, and Kazam (2017) mentions the term “Little League elbow” that refers to an overuse injury involving the medial elbow in youth baseball pitchers. It is a general descriptor of a group of conditions rather than of a specific item (Wong, et al. 2017). Medial Epicondyle Apophysitis is one of its more common meanings (Wong, et al. 2017). The injury occurs on a spectrum and involves failure at the growth plate (Wong, et al. 2017). The underlying mechanism of injury is valgus stress and medial elbow traction during the acceleration phase of pitching (Wong, et al. 2017). It is further aggravated by inadequate rest time between periods of activity, like pitching (Wong, et al. 2017). The ulnar collateral ligament (UCL) is the primary stabilizer of the elbow, and it resists valgus stress applied to the elbow joint (Zaremski, McClelland, Vincent, & Horodyski, 2017). Injuries to the UCL greatly compromise the stability of the elbow (Zaremski, et al. 2017). The UCL is commonly known from Tommy John surgery (Zaremski, et al. 2017). UCL injuries and subsequent ruptures are common among participants in overhead-throwing sports (Zaremski, et al. 2017). Damage to the UCL in the overhead-throwing athlete is a severe and potentially career-threatening injury (Zaremski, et al. 2017). This injury can be resolved with surgical reconstruction (UCL-R) (Zaremski, et al. 2017). Ulnar Collateral Ligament Reconstruction (UCL-R) has become increasingly common among players at all levels of experience since the 1990s (Zaremski, et al. 2017). Researchers have found that the number of UCL-R in youth has increased since the mid-1990s and continues to grow (Zaremski, et al. 2017). Unfortunately, this increase is expected to continue through the year 2025, particularly in athletes 15 to 24 years of age (Zaremski, et al. 2017).How each Injury Occurs Little league elbow is an overuse injury caused by stress to the inside of the elbow (Marsh, 2010). The disorder occurs in youth with open growth plates (Marsh, 2010). It commonly occurs in youth overhand pitchers but can also occur in position players in baseball (Marsh, 2010). The following factors contribute to the injury: constant overhead throwing without proper rest; improper mechanics; lack of muscle strength in elbow; and pitching too much (Marsh, 2010). According to Wells and Bell (1995), the typical incident of Little League elbow occurs in ages 9 through 14 whose enthusiasm for sports and anxiousness to participate outweigh their capabilities, which is particularly obvious in their poor pitching and throwing mechanics.  Fleisig and Andrews determined that the more common process of elbow injury occurs over a long period of time with tension to the ligament (UCL) or tissues from repeated forces across the elbow. For example, Fleisig and Andrews show in their study how the elbow is affected in a season of baseball with a pitch count of 50 to 74 which made a pitcher 21% more likely to have pain. These situations typically result in a broader area of damage to the ligament and present with typically a more gradual onset of pain and dysfunction (Healthcare). These differences are key to the understanding of how the injury occurs, the likely overall health of the ligament, and ultimately the type of treatment that should be undertaken (Healthcare).How to Prevent Injuries to ElbowFleisig and Andrews give the recommended guidelines on how to prevent injuries as follows: Watch and respond to signs of fatigue. If a youth pitcher complains of fatigue or looks fatigued, rest is suggested for them (Fleisig & Andrews, 2012). If the pitcher is complaining of pain then discontinue pitching until evaluated but a sports medicine physician (Fleisig, 2012).No overhead throwing of any kind for at least 2 to 3 months out of the year is required to help prevent from any other strains (Fleisig, 2012). Competitive baseball pitching should not be done for at least 4 months out of the year (Fleisig, 2012). Helps from the severity of how hard one throws during a game instead of in practice (Fleisig, 2012).Do not pitch more than 100 innings in a season (Fleisig, 2012).Follow the limits for pitch counts and days rest (Fleisig, 2012).Do not pitch on multiple teams with overlapping seasons (Fleisig, 2012).Learn good throwing mechanics as soon as possible and avoid using radar guns (Fleisig, 2012). A pitcher should not be a catcher for a team to reduce injury (Fleisig, 2012).Risk FactorsOshlag and Ray (2016) found a 2014 study, Yang et al., that identified several primary factors that predicted an increased risk in elbow injuries. These factors included pitching more than 8 months out of the year, pitching for multiple teams with overlapping seasons, pitching multiple games per day, pitching on back-to-back days, and pitching while fatigued or with pain (Oshlag, 2016). Pitching with fatigue, or pain places athletes at the highest risk for injury (Oshlag, 2016). It has been suggested that the loss of bodily movement, that accompanies muscle fatigue, is a primary contributor to the increased risk of injury (Oshlag, 2016). Other projected injury risk factors include pitch type, velocity, and pitch count (Oshlag, 2016). A traditional expert opinion once suggested that the early use of curveballs and other breaking pitches placed youth throwers at a higher risk of elbow and shoulder injury, according to Oshlag and Ray (2016). Oshlag and Ray (2016) found that a number of researchers have examined various pitch types as risk factors for injuries to athletes and although results vary, biomechanical analysis has shown few kinetic differences between different pitches and showed that the greatest joint loads with fastballs and the least with changeups. Researchers suggest that velocity, and not pitch type, is the primary cause of stress on the joint and surrounding structures (Oshlag, 2016). Plus, pitchers who throw curveballs/breaking balls at a young age tend to be the better pitchers on a team, and therefore have higher overall pitch counts, but, USA Baseball recommendations state that breaking pitches should not be thrown until after bone maturity (Oshlag, 2016).RehabilitationUlnar Collateral Ligament(UCL): In the non-operative rehabilitation program, ROM is initially permitted in a non-painful arc of motion, usually from 10° to 100°, to decrease inflammation and align collagen tissue (Wilk, Macrina, Cain, Dugas, & Andrews, 2012). A brace may be used to confine the motion of the elbow. Furthermore, it may be useful to rest the UCL immediately following the initial painful episode to prevent additional stress on the ligament (Wilk, et al. 2012). Isometric exercises are performed for the shoulder, elbow, and wrist to prevent muscular atrophy (Wilk, et al. 2012). Ice and anti-inflammatory medications are prescribed to control pain and inflammation (Wilk, et al. 2012). ROM of flexion and extension is gradually increased by 5° to 10° per week during the second phase of treatment or as tolerated (Wilk, et al. 2012). Full pain-free ROM should be achieved around 3 to 4 weeks (Wilk, et al. 2012). Elbow flexion/extension motion is encouraged to promote collagen formation and alignment (Wilk, et al. 2012). Valgus loading of the elbow joint is controlled to minimize stress on the UCL (Wilk, et al. 2012). Rhythmic stabilization exercises are initiated to develop dynamic stabilization and neuromuscular control of the upper extremity (Wilk, et al. 2012). As dynamic stability is advanced, isotonic exercises are incorporated for the entire upper body (Wilk, et al. 2012). The advanced strengthening phase is usually initiated around 6 to 7-weeks post-injury (Wilk, et al. 2012). During this phase, the athlete is progressed to the Thrower’s Ten isotonic strengthening program, and plyometric exercises are slowly initiated (Wilk, et al. 2012). An interval return, to throwing, is initiated once the athlete regains full motion, adequate shoulder and elbow strength, and dynamic stability of the elbow (Wilk, et al. 2012). The athlete is allowed to return to competition following the asymptomatic completion of the interval sports program (Wilk, et al. 2012). If symptoms reoccur during the interval throwing program, it is usually at longer distances, at greater intensities, or with off-the-mound throwing (Wilk, et al. 2012). If symptoms continue to persist, surgical intervention is considered (Wilk, et al. 2012). Little Leaguer’s Elbow- In the absence of an avulsion, a rehabilitation program similar to that of the non-operative UCL program is initiated (Wilk, et al. 2012). Emphasis is placed on the reduction of pain and inflammation and the restoration of motion and strength (Wilk, et al. 2012). Strengthening exercises are performed in a gradual fashion. Isometrics are prior to light isotonic exercises (Wilk, et al. 2012). In young throwing athletes, core, legs, and shoulder strengthening are encouraged (Wilk, et al. 2012). Often, these individuals exhibit poor core and scapula control along with weakness of the shoulder muscles (Wilk, et al. 2012). Stretching exercises are performed to normalize shoulder ROM, especially into internal rotation and horizontal adduction (Wilk, et al. 2012). No heavy lifting is permitted for around 12 to 14 weeks (Wilk, et al. 2012). An interval throwing program is installed as tolerated when symptoms subside, typically after an 8- to 12-week rest period (Wilk, et al. 2012). When the presence of a non-displaced or minimally displaced avulsion, a brief period of rest for approximately 7 to 14 days is encouraged, followed by a gradual progression of ROM, flexibility, and strength (Wilk, et al. 2012). An interval throwing program is usually allowed at weeks 8 to 12 (Wilk, et al. 2012). If the avulsion is displaced, an open-reduction or internal-fixation procedure may be required (Wilk, et al. 2012). To see the phases and progression of rehabilitation for both of these injuries report to Appendix A on page 14.Stages on How to Properly ThrowThe proper mechanics of baseball pitching may be divided into 6 phases for understanding (Marsh, 2010). The basic phases of pitching include the windup, stride, cocking, acceleration, deceleration, and follow-through (Marsh, 2010). The windup begins with the first movement and ends when the hand leaves the glove (Marsh, 2010). The windup is the longest phase of baseball pitching at all levels and requires elevation of the stride leg while balancing on the posting leg (Marsh, 2010). The stride begins as the hand leaves the glove and ends when the front foot contacts the ground (Marsh, 2010). During the stride phase, the pitcher continues to balance on the posting/back leg while the hips and upper torso rotate forward and the arm is elevated to the throwing position (Marsh, 2010). The cocking phase begins when the stride foot contacts with the ground and ends when the shoulder has reached maximum shoulder external rotation (Marsh, 2010). The most researched phase of baseball pitching is the acceleration phase (Marsh, 2010). The Acceleration phase begins with maximum shoulder external rotation and ends when the ball leaves the hand (Marsh, 2010). The deceleration phase begins when the ball leaves the hand and ends when the shoulder reaches maximum internal rotation range of motion (Marsh, 2010). Deceleration phase is the shortest phase of baseball pitching (Marsh, 2010). Follow-through represents the final phase of the baseball pitching and ends when the pitcher has reached a fielding position (Marsh, 2010). In order to visually see the stages of throwing and how they should be performed/executed refer to Appendix B on page 15.ConclusionElbow injuries in young baseball pitchers and position players is a rising issue throughout the sport that has drastically increased in just the past 30 years (Zaremski, et al. 2017). Athletes between the ages 11 to 18 are putting stress on their elbow, and this makes them vulnerable to injuries like Little Leaguer’s Elbow and Ulnar Collateral Ligament (UCL) tear (Zaremski, et al. 2017). In order to take care of the injuries, the athlete must follow guidelines given to help strengthen it, and other possible ways as well are given to improve the overall health (Wilk, et al. 2012). Many kids aren’t knowledgeable of their arm and how it is in danger of injury, and they need to know how to properly take steps to prevent them (Wilk, et al. 2012). In order for kids to be knowledgeable they must be shown and informed by research what they need to know for the health of their arm (Zaremski, et al. 2017). For elbow injuries to slow down in the future, parents/athletes need to look in depth at all the ways an injury can occur and try to prevent them from happening. Kids should be able to grow up having fun in the sport instead of always in pain and being sat out for a long time due to improper use of their elbow.       ReferencesFleisig, G. S., & Andrews, J. R. (2012, August 1). Prevention of Elbow Injuries in Youth Baseball Pitchers. Retrieved October 30, 2018Marsh, D. (2010). Little League Elbow: Risk Factors and Prevention Strategies. Strength and Conditioning Journal,32(6), 22-37Matsuura, T., Suzue, N., Kashiwaguchi, S., Arisawa, K., & Yasui, N. (2013). Elbow Injuries in Youth Baseball Players Without Prior Elbow Pain. Orthopaedic Journal of Sports Medicine,1(5), 1-4Oosterwijk, A. M., Nieuwenhuis, M. K., Schouten, H. J., Schans, C. P., & Mouton, L. J. (2018). Rating scales for shoulder and elbow range of motion impairment: Call for a functional approach. Plos One,13(8), 1-13Oshlag, B. L., & Ray, T. R. (2016, September/October). Elbow Injuries in the Young Throwing Athlete: Current Sports Medicine Reports. Retrieved October 30, 2018, 325-329Shanley, E., & Thigpen, C. (2013, October). Throwing Injuries in the Adolescent Athlete. Retrieved October 30, 2018, 630-640Viegas, D. (2018, July 10). Sports Injuries and pitching pain. Retrieved October 30, 2018Wells, M. J., & Bell, G. W. (1995, September). Concerns on little league elbow. Retrieved October 30, 2018, 249-253Wilk, K. E., Macrina, L. C., Cain, E. L., Dugas, J. R., & Andrews, J. R. (2012, September). Rehabilitation of the Overhead Athlete’s Elbow. Retrieved October 30, 2018, 404-414Wong, T. T., Lin, D. J., Ayyala, R. S., & Kazam, J. K. (2017). Elbow Injuries in Pediatric Overhead Athletes. American Journal of Roentgenology,209(4), 849-859Zaremski, J. L., McClelland, J., Vincent, H. K., & Horodyski, M. (2017, October 16). Trends in Sports-Related Elbow Ulnar Collateral Ligament Injuries. Retrieved October 30, 2018, 1-7                  Appendix A    (Shanley & Thigpen, 2013)       Appendix B    (Viegas, 2018)MethodsParticipantsIn this study there will be 120 participants overall; 60 pitchers and 60 position players. There will be 2 groups involved: Group 1- Ages 11 to 14 and Group 2- 15 to 18. In each group, there will 30 pitchers and 30 position players who are all males but, no particular ethnicity needed. The researcher will make sure that none of the athletes have any previous injuries and are in good health. This will be determined through a survey/questionnaire for any previous injuries and to be able to see the ages. The previous injuries, if any, will be seen after they take the survey before they sign the contract to participate in the study. After the athletes have been seen and are clear to participate in the study they will then be given an informed consent form to warn of possible injury and also get permission to document them and all their data from the season.MaterialsThe velocity and speed gained or lost will be accounted for by coaches and other players. For example, like pitchers who aren’t going to pitch at all for that game. The position players would be recorded on how many throws they have per game. This information can be written down on a spreadsheet. The equipment used will be radar guns; spreadsheet on excel; and a tablet or computer to be able to keep up with all data throughout the season, or at the end of the season.Research DesignEach athlete will be evaluated from February to June. The pitchers will be evaluated on how many pitches they throw (game & practice). Position players will be evaluated by how many throws they have throughout (game & practice). Rest days will also be taken into account. For each group, half of the pitchers will be given a pitch count (50 for Group 1 & 75 for Group 2) and the other will not have any at all (to be able to see a difference in having one vs not). For example, 15 pitchers will have a pitch count of 50 while the other 15 has 75. Pitchers will also be assigned warm-up times but half will do 15 to 20-minute warm-ups while the other half does 30 to 45 minutes (again want to see difference/effects of shorter vs longer warm-up times). The position players will be assigned warm-up times too. They will be divided just like the pitchers, half doing 15 to 20 minutes and the other 30 to 45-minute warm-ups for each age group. Position players will not be given any pitch count, but how many throws they have each game will be documented, half (15 and 15) will be given a minimum of 50 throws while the other half is at least 70 throws per game. If possible by the pitchers throughout the season, the researcher would prefer them to throw around 50 innings each. Some factors that would need to be considered during the study would be weather, playing surface, the quantity of playing time, and anatomy.ProceduresWith no injuries known, the athletes will resume their season with practice and games. they will participate until the end of the season unless an injury occurs and if it does happen everyone in the group is still participating in the study. The other participants will still proceed, except for the one possibly injured. If an injury does happen, then the athlete will be sent to a doctor to confirm. The results will be sent back to the researcher from the doctor and the doctor will decide and let the researcher know on whether to end the subject’s season or just let them sit out for a period of time and start back throwing again. If it’s major damage, tear, strain, etc. then the athlete will be done participating in practice or games. Their name will be marked/highlighted (in red) to let researchers know the player is injured. Even the players that have minor pain or discomfort they will be marked/highlighted as well (in yellow) but doesn’t mean they should be sat out yet; they just have to be cautious. At the end of June, the study will close and each age group will be calculated separately with the pitchers separated from the position players. All elbow injuries, if any, will be compared between the 2 groups to see which group was more prone to injury or what caused others with being uncomfortable (pitch count vs none; short warm-up vs long warm-up). Also, this study can be used to see how the pain/ “uncomfortable feeling” in the subject’s arm felt due to their no pitch count or rest days, and improper warm-up.