High Volume Participation in Overhead Sports: is it worth it?
This is the second article regarding healthy participation in overhead sports as a youth athlete. Overuse injuries occur in 30% of youth baseball and softball players and can cause lifelong impairments. Adequate recovery time, correct throwing mechanics, and building a healthy musculoskeletal base are the primary way to create injury-proof baseball and softball players.
Parents: imagine that your child asks to participate in an activity that has a 30% chance of causing joint pain, and in extreme cases, can lead to altered skeletal growth and limb deformities. What would your response to such a request be? Most parents would likely balk to allow their child to do this, and those who did would do everything possible to mitigate their child’s risk of injury.
Now, if I told you this “activity” was a sport, and then asked you which sport you believed to carry these risks, what would your response be? Many parents would say football, gymnastics, lacrosse, or hockey – the sports typically associated with severe injuries. However, the sports that I am referring to in this case are youth baseball and youth softball.
As discussed in my last article, What is “normal” youth sports participation?, the landscapes of youth baseball and softball have changed immeasurably in the past 10-15 years. School age athletes routinely play over 100 games in one summer. This does not include their school season or fall ball. For reference, MLB teams play 162 games in their regular season. As a Division III college softball player, the maximum number of games I played in a regular season was forty. My friends at the Division I and II levels played between 45 and 70 games. As musculoskeletally mature adults, none of us came close to playing the number of games that youth athletes are currently playing.
What was the reason for such a change?
There are many factors to consider, but from my own observations, it is the exponential growth of travel ball and “elite” organizations. Parents and players are under the impression that the only way to find success as an athlete is to be part of such an organization. Rather than participating in local rec leagues, families opt to join teams that promise attention from college coaches and higher levels of competition, starting as young as ten years old.
The huge influx of players to travel and elite organizations has provided more opportunities to play games in this setting, and teams play in summer, fall, and winter tournaments. In many organizations, players are expected to participate in all seasons, and there are penalties for absences, even if it is for another sport.
With the increase of games played has come an increase of overuse injuries in youth athletes. Four and five day-long tournaments have crowded out practice times, as have travel demands to get to tournaments located in different parts of the country. Lack of practice time creates an incomplete athlete; practice provides the opportunity to ingrain the skills needed to be successful during a game. This happens through deliberate team activities and drills with high levels of repetition. The effort expended during this time is submaximal, conditioning muscles and other soft tissues to perform sport-specific movements safely. The change in the practice to game ratio has forced athletes to perform maximal effort repetitions without an adequate training base to support it, and to do so with increased frequency and decreased recovery time. To offer some perspective, musculoskeletally mature college athletes expected to practice 4 to 5 days per week in season, with 2-3 competitive days and one day off therein.
What happens without adequate conditioning and recovery?
Bony injuries
Every joint in the body has an established normal “range of motion” determined by its anatomy. Movement beyond this range is meant to be an occasional activity, as it requires some strain to the anatomical structures comprising the joint (i.e.: muscles, tendons, ligaments, and joint capsules). If these demands are placed on the body repetitively, it leads to trauma of these structures, whether in the form of inflammation, tears, sprains, strains, or stress fractures. The increased force required by maximal effort repetitions creates greater trauma to these tissues.
When the demand placed on the body cannot be accommodated by one or more tissues, muscular imbalances develop and cause abnormal movement patterns and inflammation. In overhead athletes, muscular imbalances most commonly occur in the muscles of the rotator cuff and the muscles that control the shoulder blade, which are in the upper and middle back.
One such pathology is Little League Shoulder, which is caused by inflammation of the growth plate where the humerus (upper arm bone) joins the shoulder blade. This occurs most commonly in athletes ages 11-14 years, which is the time for rapid growth spurts. Though it affects the bone and shoulder joint, it is caused by muscular imbalances. During a growth spurt, there is a large amount of activity in growth plates as they produce bony tissue to lengthen the skeleton. As bones lengthen, muscles must also lengthen, which is a slower process. When a youth athlete places extreme demands on immature muscles, such as constantly loading in an extreme range of motion without a chance to adapt or recover, it causes trauma to the joint, resulting in inflammation. Inflammation can become severe enough that the growth plate can separate from the bone, causing permanent damage to the shoulder joint. A similar injury can occur to the growth plates of the elbow joint under the same stress. Both injuries may require surgery to repair and potentially alter the growth of the bones that comprise the elbow and shoulder joints.
Both Little League Elbow and Little League Shoulder require a lengthy hiatus from sport to ensure adequate recovery. On average, true recovery takes 2-3 months after non-surgical management. Following surgical management, recovery time will depend on the individual surgeon’s post-operative protocol and the patient’s ability to participate in physical therapy. Typically, it is four months before return to throwing, which begins in a carefully planned progression. Programs for throwing progressions are 6-8 weeks in length. This all means that, at a minimum, the athlete will have to sit out for six months before being adequately recovered to participate in his sport.
Muscle, tendon, and ligament injuries
Injuries can occur to the soft tissues themselves due to muscular imbalances in the rotator cuff and upper back. One common problem is shoulder impingement, which when left untreated, can lead to a rotator cuff tear. A shoulder impingement causes shoulder and arm pain when the athlete reaches overhead, across his body, or behind his back. This occurs because the muscles that control shoulder blade movement are not strong enough to accommodate the demands of high-volume throwing. As a result, the athlete develops compensatory movement patterns that cause tendons of the rotator cuff to be pinched by the bones of the shoulder joint. When such trauma is applied repetitively, the “pinching” can cause a tendon tear. This is always a surgical issue that requires 6 months of recovery time.
Less severe injuries such as muscle strains and ligament sprains are signs that an athlete is experiencing muscular incoordination and weakness. In these cases, the affected muscle or ligament is being overused and experiencing “tissue failure,” which means that parts of it are tearing because they are being loaded more than is anatomically appropriate. Such seemingly mild injuries should not be ignored or “played through,” as they are signs that something is musculoskeletally abnormal. Physical therapists and physicians recommend two weeks of total rest from sport once pain and inflammation begin, followed by a rehab program to address the imbalances that have led to the sprain or strain.
How to protect youth overhead athletes from injuries
Rest from overhead sports is a non-negotiable part of injury prevention for youth baseball and softball players. For elementary and middle school aged children, this means no more than 8 total months of participation in baseball or softball per calendar year. By high school, this can be reduced to two months off from sport.
It is also very important to ensure that pitchers, whose position requires high throwing volumes at baseline, have sound throwing mechanics before beginning a season. This means that they rely on their hips and core muscles to drive movement rather than using their arm and shoulder to produce velocity. The lead foot should be pointed towards home plate and in contact with the ground before the arm begins its forward motion. This will keep the chest closed and reduce strain on the elbow and shoulder. Finally, hand and wrist position will affect arm and shoulder mechanics. The wrist should be held straight, what is called a “neutral” position. (The palm is in line with the forearm.)
If a child complains of muscle or joint pain when participating in a sport, parents and coaches must take it seriously. When injuries are detected early, conservative care measures such as physical therapy and rest are very effective and provide a foundation for safe participation in sports. As joint pain and abnormal movement patterns persist, the likelihood that the athlete will require surgery and protracted rehabilitation increases. This can even lead to permanent joint damage, decreased growth rates, and even skeletal deformities. If parents and coaches suspect that the child is “faking” the injury, this warrants attention as much as any other complaint. This indicates that the child does not want to participate in his sport and continuing to push him to do so can lead to problems with mental health as well as a decline in the quality of relationships with parents, friends, and coaches. It is highly worthwhile to investigate the “why” behind the complaint.
In the current youth sports climate, these recommendations are not likely to be popular. There is constant fear that if an athlete is not playing, he is falling behind. This is highly incorrect, as rest and recovery enhance an athlete’s ability to participate in his sport. Increased skeletal growth has been documented during recovery periods. During “non-traditional seasons,” athletes are best served by participation in a strength training program or completely different sport. College and professional coaches and scouts are more interested in multi-sport athletes than those who specialized early or played year-round instead of giving their bodies adequate recovery time. They are more interested in an athlete who is likely to have a long and healthy career than one who “used up their arm” in 14-and-under travel ball.
As summer winds down, let’s give baseball and softball players a chance to rest and recover so they can go into next year’s season ready to play.
Dr. Claire Kopko, PT is a former collegiate softball player with extensive experience in strength & conditioning and pediatric sports medicine. Please reach out to her with concerns or questions regarding participation in overhead sports.
