Did my 9-year-old throw his shoulder out playing baseball?

A baseball parent recently came into our clinic with his son. The 9 yr-old pitcher was experiencing shoulder pain in the top and back of his dominant throwing arm, but only when he was throwing a ball. Because he played on an active club team,  his arm had few days off from throwing and catching.

While playing the battery makes you an effective baseball player, it can be hard on the body. That’s because this position combines both pitching and catching, resulting in the most throws per week of any position combination in baseball.

To figure out what was going on, we brought the young ball player into the Integrative Sports Medicine office for a throwing and pitching analysis using his own baseball equipment. Our analysis led us to some very interesting observations.

Throwing and pitching analysis

We asked the young boy to bring his baseball gear and demonstrate an authentic throw and catch that he may do during a game or practice session. During the assessment we asked him tons of questions so we could understand the full context to his situation.

What was uncovered:

  1. Muscle overcompensation
    Lackluster power generation in the thigh, butt and back muscles led to an overcompensation in the shoulder. He also tended to drop his elbow and throw with more displacement of the elbow when tired or unfocused. This was creating increased stress on the shoulder and elbow. An imbalance of arm velocity is developmentally normal for a 9/10-year-old and is fixable in a gifted and coachable student-athlete.
  2. Chronic shoulder pain and problems
    Physical exam findings consistent with mild, chronic and repetitive shoulder impingement, likely as result of sloppy arm control during follow through set up by imperfect mechanics from cocking phase through delivery. He also has congenital shoulder laxity (multidirectional instability or MDI). This is consistent with his mother being a hitter in volleyball and also consistent with his ability to put his shoulder through a large range of motion, which in part correlates with arm and ball velocity.
  3. Regular ultrasound results
    A basically normal ultrasound showed mild fluid in the joint but nothing severe. There were no torn structures.
  4. Back to baseball basics
    By asking lots of questions about his past training, we could tell that he knew the basics of how to throw a ball. Due to his age-appropriate brain development, he did not actually realize that he had already gotten pitching coaching but had not consciously linked the throwing elements into a sequence during his pitching motion. He didn’t realize that the purpose of his coach’s drills were for which is completely normal for a 9/10-year-old kid. In fact, when he followed the fundamentals that his coaches had already taught him and put them all together, he had a very good to excellent motion and no pain at all.

The most interesting part of the throwing analysis was that the patient was able to correct his throwing “errors” simply by getting him to remember his deliberate coaching. His coaches have come up with cleverly worded drills to get players to use other muscle groups that activate supportive muscle groups, such as the gluteals, to throw from the lower extremity and back.  For example, when the player incorporated “fart and flush” and “towel drill” together within the same pitch, there was less force on the shoulder and elbow and yet the pitch came in with excellent pace and accuracy. Another observation is that the patient reported a history of throwing for a radar gun, which is common, but in modern Sports Medicine is recommended for all student-athletes at all times.

Raising student athletes

This is a student-athlete who is lucky enough to play in a very sophisticated system of baseball. By dissecting his coaching tips, linking them into a single throw and correcting a tendency to drop his elbow when fatigued or not paying attention, his throw was completely fixed (for now) and he threw better and with less shoulder pain.

It is difficult for a coach to have time to spend large amounts of time with every individual thrower on the team to assess where the player is cognitively in understanding what he is being taught and how to use it.  There are literally not enough hours in the week when dealing with schedules, rosters, parents, and leagues, not to mention the other jobs and family responsibilities coaches have.  However, it is possible for a 9/10-year-old to understand and correct a throw when the coaching base is there and a thorough examination and analysis are turned into a conversation with the student-athlete coupled with actual throwing in real time.

Our success this time had everything to do with having a well-coached student-athlete with very supportive parents with great communication skills and not excessive pressure on the child.  All that made my job a lot easier. It’s important to keep the long-term in mind and not this year’s radar ratings and winning percentage/ERA and championships at the forefront.  I struggle with this myself as a parent.  These are children, not professional athletes and it can be hard to remember (just not in this case) how young they are at times.

From our research-filled and parent and coach friendly website, https://www.stopsportsinjuries.org/ with which I am the official affiliate for Northern Colorado, the max pitches you are allowed to throw per day at this age is 75 pitches, with outings being 4 or more days apart.  This is based on a lot of guesswork and common sense about what we are seeing, admittedly, and not particularly rigorous, hard data.  Despite our shortcomings as scientists, it is fair to agree with the book The Arm by Jeff Passan.  We are in an epidemic of shoulder and elbow injuries occurring at younger and younger ages.  Jeff Passan’s book mainly deals with the epidemic related to Tommy John surgery, so it can be more featured in a future article about the ulnar collateral ligament, but the epidemiology of injury also applies to shoulder overuse injuries in throwers.

Further commentary: there is no role for corticosteroid injections.  These student-athletes need healing time and activity modification, not a drug that shuts down healing, weakens connective tissue of the body and masks injury.  For an older player, regenerative medicine could be appropriate.  A 10-year-old has plenty of growth factors and stem cells in the area of any injury, so changing the biomechanics of the throw and allowing time for healing should be completely sufficient and no medical procedures should be needed.

This player was returned to play on a limited but increasing schedule to be supervised by parents and coaches, including the use of pitch counts and frequent check-ins with the player as to whether he is experiencing discomfort.  If we have learned nothing else over the past 100 years of baseball in this country, it is that injuries can start with minor discomfort, which if ignored can become major injuries with just a few more pitches.  Communication between players and coaches needs to be nurtured into an environment of comfort, honesty, and complete transparency.  We all know that is a major feat when dealing with pre-teens and teens, but it might be the best thing we have to prevent minor injuries from becoming life-changing injuries.

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