Arm care part one

Our two-part “Arm care” series features a Q&A with two of the foremost experts on shoulder and elbow injuries:

Dr. Michael G. Ciccotti is a Professor of Orthopaedic Surgery, Chief of Sports Medicine, and Director of the Sports Medicine Fellowship at Thomas Jefferson University. He also serves as the Head Team Physician for the Philadelphia Phillies, and is the President of the Major League Baseball Team Physicians Association.

Michael Ciccotti

Michael Ciccotti

Dr. W. Ben Kibler is a board-certified orthopedic surgeon specializing in sports medicine and shoulder and elbow conditions with the Lexington (Ky.) Clinic. He has worked with professional baseball since 2001, and has been involved in spring training medical education for all levels of the Houston Astros’ sports medicine staff. He received his M.D. from Vanderbilt University, where he was an All-SEC outfielder for the Commodore baseball team

WHY WERE THERE SO MANY ARM INJURIES AT THE MLB LEVEL THIS YEAR?

Michael Ciccotti: There are so many theories as to why there seems to be an epidemic of pitchers with UCL and other catastrophic injuries. One of the theories is the sports specialization that occurs so early in life. These pitchers that are currently in Major League Baseball in their first, second, or third year seem so protected, pitching every fifth day and with very strict pitch counts. In spite of that, we have this high incidence of catastrophic injury, whereas decades ago we had pitchers that would pitch every fourth day and with virtually no limit in terms of pitch counts in a single game.

Ben Kibler

Ben Kibler

Ben Kibler: First of all, it appears that the actual number of elbow and shoulder injuries is going up across the board from about age 15 on up. Secondly, our ability to treat these injuries is less than sterling. We operate on these people and they don’t get back to 100 percent and sometimes not even close to 100 percent.

We seem to hear a lot that players do better after Tommy John surgery and there is some evidence that for a short time you can achieve a level of competitiveness again, but it takes over a year and it makes the career shorter in the long-run. The point is that the treatment is not the answer.

The third point is that the impression of the major league team physicians and medical staffs is that they’re having to play “catch up” once players get into their system. There are a lot of miles on arms and other injuries on these guys once they show up. [The physicians and medical staffs] feel that there is a higher percentage of guys that are being drafted that have some wear and tear, stiffness, bad mechanics, a lot of things that make it harder for them to succeed at the highest level.

DO YOU CRINGE WHEN YOU WATCH THE LITTLE LEAGUE WORLD SERIES?

MC: Particularly being from Philadelphia and following the Taney Dragons, there’s something that’s so wonderful about the Little League World Series, from a pure sport perspective. To see how that event captured the fourth-largest city in the United States was so spectacular, and I would bet the same for Chicago and Las Vegas. That pure joy of sport was so wonderful. I know the head coach well for the Taney Dragons, and I know that they believe in the things that we’re talking about here. I’d like to believe that all youth coaches across the United States follow that, but I know the reality is that’s not the case. In spite of how wonderful it is, we as medical providers need to be conscious of the fact that there will be coaches, parents, and players that deviate from what we suggest, and that can ultimately lead to injury. We have to be vigilant.

STEPS TO A SOLUTION

BK: At the major league level, there’s a growing concern, and the MLB commissioner’s office and organizations have formed task forces to look at shoulder injuries, elbow injuries, hip injuries and concussions. The teams have a lot of interest in the best players and putting out the best product possible, so we are looking at working with the coaches in a more direct way, telling them what we see, what our needs are, and asking for their help in working together to getting these guys into professional-level performance.

MC: The former commissioner and the current commissioner are so focused on this; they really want nothing but the best for professional baseball players. Our research is quite focused on specific topics, but this is an area of intense scrutiny. An elbow research focused group (particularly with UCL injuries) has been established and we coordinate with some very notable elbow specialists (James Andrews, Dave Altcheck, among others). We need to figure this out. It applies certainly to UCL injuries, but there’s a broader application to figuring out other injuries. I think a lot of the principles that will follow will apply to those other areas. Dr. Kibler has been a huge proponent of the kinetic chain and establishing it in the orthopedic world. We believe that this idea, this ‘balance’ from the ground up is vitally important in offloading the far end of the chain [the shoulder and the elbow].

WHAT SHOULD COACHES BE DOING WITH THEIR PLAYERS (PARTICULARLY PITCHERS) IN THE OFFSEASON?

MC: Have a respect for the repetitive activity, the amount of exposure these athletes are involved in. Professional ballplayers will very often take three months off, whereas youth players are literally playing throughout the year. The recruiting system has created this need to continuously play baseball, but the feeling is that maybe some of these injuries are a result of that repetitive exposure. The guidelines are out there for youth athletes, and James Andrews has done a great job codifying that, so they’re available. Having a respect for the fact that many of these baseball players, particularly pitchers, may go on to the next level is also vitally important.

BK: Dr. James Andrews recently named showcases, radar guns and travel teams as the three worst things for young arms because they’re putting too much emphasis on the wrong things. I played baseball about four or five months a year. There was a recent article that found that on MLB roster, a higher percentage of pitchers came from traditionally cold-climate areas, and that a higher percentage of hitters came from warm-weather climates. The northern pitchers didn’t throw as much and the southern hitters saw more pitches. Just like in tennis, a lot of the players that make it professionally are not growing up playing one sport.

There should be at least three months off before you go back to picking up a baseball. We just finished our season with the Royals and our guys have gone home. In October, November and December, our guys are instructed not to pick up a baseball. That’s what the guys that are being paid do, so if you’re 15 or whatever, that might be something to think about.

HOW CAN YOU LEARN FROM THE OCCURRENCES OF UCL SURGERIES OVER TIME?

MC: From the early 2000s to 2012, the incidence of UCL surgeries in Major League Baseball hovered in the mid-teens. Then it jumped up in 2012 and went back down in 2013; now in 2014 it’s back up again. The hope is that’s it’s another odd ‘blip,’ but it may not be. We aim to determine the real epidemiology of this injury. We plan on prospectively evaluating these athletes to see what happens over time, with physical exam, imaging parameters (i.e. MRI studies and stress ultrasounds) and biomechanical evaluations in order to see what happens to these players longitudinally. Unfortunately, some of these players will incur these injuries, so you have to look at that injured subset in order to determine how they differ from the ballplayers that remain injury-free. That way, we might be able to determine some predictive factors that we can then apply going forward. So if an athlete is identified with those risk factors, we can institute preventative measures such as optimizing mechanics, focusing on kinetic chain conditioning, and providing appropriate rest, all in order to insure that we are controlling everything that we can control to prevent injuries from occurring.

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