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Photo from Bleacher Report

Shoulder surgery is a big concern for any professional pitcher.  I am currently rehabbing two MLB pitchers (one from a labral repair and the other from a Tommy John procedure and obviously not JV pictured above). They are doing great so far in their early rehab, but time will tell if they make it back to their pre-injury pitching levels.

Overuse injuries in youth baseball players is always a huge concern I have.  In fact, I speculate that early wear and tear may contribute to injuries seen down the road in HS, college or the pro ranks.  I know from coaching and observing that more youth coaches need to familiarize themselves with pitch count guidelines and rest/recovery recommendations that Little League baseball now endorses.

As a sports physical therapist who sees 12 year-olds with RC problems and torn UCLs and as a father/coach of a 10 y/o left-handed pitcher, I have a strong passion and vested interest in the welfare of baseball pitchers. While research does not equate increased injury risk with throwing curveballs and sliders to date per se, both of my MLB clients advise against it until athletes turn 14 or 15.

For  information on injury prevention and pitching guidelines for youth, check out this website:

http://www.asmi.org/research.php?page=research&section=positionStatement

Today’s blog post focuses on outcomes following surgery for elite pitchers.  The following information was just published in the Jul/Aug 2013 edition of Sports Health by Harris et al. based on literature review based on these outcome measures:

Primary = pitcher’s rate of return to sport (RTS) at the same level prior to injury

Secondary = rates of RTS regardless of level, performance upon RTS and clinical outcome scores

“Elite” was defined as throwing in at least one game in MLB, minor league (A, AA, or AAA) or all collegiate divisions.   Six level I-IV studies were included with enrollment from 1976 - 2007, and there were 287 elite male pitchers who underwent shoulder surgery with 99% on the dominant throwing shoulder.  Most pitchers (276) were professional with a mean career length of 6.58 years.  Post-operative clinical follow-up within these studies was 3.62 years.

Primary diagnoses treated:

  • RC tear = 120 (43%)
  • Internal impingement = 82 (30%)
  • Labral tear = 74 (27%)

Surgical procedures performed:

  • Labral repair (157) or labral debridement (99)
  • RC repair (29) or debridement (162)
  • Thermal capsulorrhaphy (63)
  • Subacromial decompression (42)

The statistics reveal more debridement of the labrum (61%) and rotator cuff (85%) versus repair.  This is not necessarily surprising given the desire to minimize surgical intervention and loss of motion.

Return to Sport Data

  1. The overall rate of return to sport was low at 68%.
  2. Mean time to return to competitive pitching in a game situation was 12 months (range = 9 -17)
  3. 22% of MLB pitchers never pitched again in MLB
  4. Only 14% returned to competitive pitching in the same season as labral surgery
  5. No one returned to competitive pitching in the same season after rotator cuff surgery
  6. Reynolds et al reported a median of 2 seasons of pitching after debridement of partial thickness cuff tears
  7. Mazoue and Andrews reported a mean of 0.7 seasons pitching (range 3 innings to 3 seasons) after mini-open RC repair

Performance declined for the 3 seasons prior to surgery and then gradually increased for 3 seasons afterward, but generally did not reach pre-injury levels.

Challenges with this review include selection bias given that many of the pitchers had concomitant pathology present. Retrospective review only adds to that bias.  Additionally, performance bias with extraction of public data, transfer bias related to different lengths of clinical and professional follow-up and detection bias attached to different methods of post-op evaluation were also present here.  All of this was readily acknowledged by the authors.

Despite all that, the information is useful in that it tells us as practitioners we must be on the front lines of injury prevention and arm care to help reduce the # of surgeries.  Evidence suggests that GIRD, scapular dyskinesia, overuse and proper mechanics all matter.

As therapists, we must address posteroinferior capsular tightness through proper mobilization and stretching.  I have seen this resolve shoulder and elbow pain in many throwers I have cared for with significant GIRD.  While I understand the concept of Total Shoulder Motion and the “pseudolaxity” in the anterior capsule that accompanies chronic throwing, I do not fall in the camp of those who feel loss of IR is fine as long as total motion or arc is the same side-to-side.

Sleeper stretching is controversial in the rehab ranks, but when used appropriately I have seen it help eradicate pain in many throwers I treat.  Based on my clinical experience, the risk for internal impingement is too high if GIRD is marked and greater than 10 degrees in most cases.  I routinely see GIRD of 15-20 degrees in many throwers from age 12 to MLB players.  My client who I am seeing for Tommy John had shoulder issues the year prior to his UCL injury.  He rehabbed the shoulder, but then the next year in Spring training his UCL tore.  Coincidence?  I think not.

I also worked with an aspiring collegiate catcher last summer who had “dead arm” at the end of his senior year in HS.  He saw three orthopods.  Two recommended surgery for a torn labrum.  The Doc I work with said go to PT - no labral tear and just need to rehab the shoulder.  He presented with internal impingement and questionable labral signs on exam.  He had GIRD greater than 10 degrees.  I worked extensively on mobilization and posteroinferior capsular stretching along with a RC/scapular stabilizer exercise program.  In 4 weeks he was throwing again with no pain, and he went on to play the next year in college without surgery.

So, addressing this tightness and reducing poterosuperior humeral head migration in pitchers will help reduce “peel back” stress and moments and likely help decrease labral injuries and internal impingement.  Teaching the players to continue arm care once the pain resolves is a must if they wish to stay injury free.

In the end, prevention is the goal.  Teaching proper stretching and strengthening programs will help.  Educating coaches about pitch counts and rest is a must.  Finally, we must ensure parents do not allow their children to play for multiple teams and try to minimize/eliminate the pitch and catch combo as their arm stress s too high and their risk for injuries rises in proportion with the # of throws on the arm.

I look forward to helping as many players as I can avoid surgery.  In addition, I look forward to doing everything in my power to get my pitchers all the way back to throwing like they know how.  Part of that is preventing another injury in the future.  Help me in this prevention effort by educating those around you.

For more info on preventing overuse sports injuries, visit http://www.stopsportsinjuries.org.

Click here for another article in Sports Health related to shoulder and elbow surgery