Previous Work in the
Area of Injuries in
Youth Throwing
Athletes
And
Study Goals for AOSSM
Jeff Dugas, MD
Albright JA, Shaw S, et al
 54 Youth pitchers over a season
 Video and questionnaire
 More injuries with side-arm throwing
 5 arm slots described
 Lower slot leads to higher injury rate
 No control or review of trunk position
 May decrease validity
Fleisig et al 1999
 J Biomechanics 1999
 23 youth, 33 HS, 115 college, 60 pro pitchers
 16 kinematic (11 pos, 5 velocity), 8 kinetic, 6
temporal parameters
 16/17 positional and temporal parameters were
found to have NO DIFFERENCE
 All 8 kinetic parameters increase with age
 Children should be taught proper mechanics
and gradual strengthening
Lyman S, et al
 Med Sci Sports Exerc 2001
 298 pitchers over 2 years
 26% elbow pain, 32% shoulder pain
 Risk Factors Elbow:
 Age, weight, decreased height, lifting weights
during season, multiple teams, more than 600
pitches per season, pitching while fatigued
 Risk Factors Shoulder:
 Pitching with fatigue, more than 75 pitches per
game
Lyman S, et al
 AJSM 2002
 476 pitchers (age 9-14) over 1 season
 Pre-/post-season questionnaires, pitch cts,
video
 52% increase in risk of shoulder pain with
curveball use
 86% increase risk of elbow pain with
sliders
 # of pitches increases risk
Sabik M, et al
 Video data on 14 youth pitchers
 Fastballs only
 18 Nm peak elbow valgus torque just
before max ER
 Weight was closest correlation with force
 Limiting exposure was best way to
prevent injury
Petty D, et al
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AJSM 2005
27 High School UCL recon
74% return to same or higher level
85% had one or more risk factors
67% began throwing breaking pitches
before age 14
 Velocity average 83 mph (high)
Sabick M, et al
 AJSM 2005
 14 elite youth pitchers, age 12
 Video analysis
 Peak ER torque =17.7Nm just before max
ER
 Shoulder distraction force of 214 N at ball
rel.
 Shear forces more than adequate to create
physeal injury
Olsen S, et al
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AJSM 2006
95 adolescents with Shoulder surgery
45 with no surgery
Injured athletes had:
 More months per year throwing, more games per year,
more innings per game, more pitches per game, more
pitches per year, more warm-ups per game, more
starters than relievers
 More showcases, pitched with pain, used NSAIDS,
were taller and heavier
 Private instruction made no difference
 Age at onset of breaking pitches made no difference
Dun S, et al
 AJSM 2008
 Biomechanics study with markers/video
 Torques not different on three throws of
fastballs and curveballs
 Curveballs may not increase risk of elbow injury
 Volume of throwing increases risk
 Does fatigue of peri-articular musculature
lead to increase stress on joint/ligaments?
Nissen et al
 AJSM 2009
 Biomechanical study with three throws
 Moments on shoulder and elbow are less
with curveball than fastball
Study Goals
 Utilize AOSSM resources, particularly its
members to:
 Create and maintain a database of youth
throwing athletes
 Collect epidemiologic and demographic
information on a large group of at-risk athletes
 Report on the injury risks, incidence and
occurrence of injury
 Make suggestions about injury prevention
Youth Baseball
Pitching Studies
Joseph H. Guettler, M.D.
Member, AOSSM Research Committee and
Study P.I.
Director, Beaumont Sports Medicine Education
and Research
IRB Approval:
 William Beaumont Hospital
Royal Oak, Michigan
The Study:
 Nationwide project looking into the epidemiologic risk
factors related to shoulder and elbow injuries in youth
baseball.
 This study will seek to define risk factors related to both
acute and overuse injuries, as well as factors
contributing to adaptive changes in the developing
shoulder and elbow.
 The goal of this project is to build on previous studies,
and create the largest youth pitching database in the
world.
 With this information, the AOSSM will be able to make
authoritative recommendations – that are based on firm
science – to youth baseball organizations, parents, and
coaches.
Study Description:
Two Study Limbs:
 Office-Based Questionnaire
 League-Based Questionnaire
Inclusion Criteria:
 As many AOSSM and ACSM members
as possible
 Youth baseball pitchers between the
ages of 9 and 18
 Pitchers presenting with injuries to the
physician’s office
 Pitchers actively involved in youth and high
school leagues who can describe their
history via a questionnaire – whether they
have had injuries or not
Design Rationale:
Design Rationale:
Treatment Patterns:
Treatment Patterns:
Study Hypothesis:
 Certain risk factors, including throwing
year-round, contribute to an increased
incidence of shoulder and elbow
problems in youth baseball pitchers
Ultimate Study Objective:
 What separates this kid from…
This kid?
Thank You!
Please Encourage Your
Colleagues to Get Involved!
The Institutional
Review Board (IRB)
Process
Bart Mann
AOSSM Director of Research
Determining IRB Coverage
 Am I already covered by an IRB through
my hospital or academic institution?
 If yes, you most likely will need to submit an
application through them
 The exception is if you are able to get your
Research Department to write a letter of deferral
 If no, you may obtain coverage through the
IRB at the study principal investigator’s
institution (William Beaumont Hospital in
Michigan)
If You Are Already
Covered…
 Obtain the forms required by your IRB for
Expedited Review (usually available on the
website of your institution)
 Download the IRB templates for the studies
from the AOSSM website
(www.sportsmed.org/tabs/research/youthbaseballstudies.aspx)
 Cut and paste elements from the templates
into your institution’s forms
 Submit all required forms to your IRB and
wait for the good news
If You Don’t Have An
IRB…
 Email me (bart@aossm.org) to obtain Research
Conflict of Interest Forms
 Register for the on-line course in research through the
Collaborative Institutional Training Initiative (CITI;
www.citiprogram.org)
 Select “William Beaumont Hospital Research Institute” as
the Participating Institution
 for Item #1, “Course in the Protection of Human Subjects,”
just check the box by MANDATORY.
 On the next page, check No that you do not want to be
affiliated with another institution.
 Then you are set to take the course which will take about 3
hours
 Email me the Certificate of Completion along with the
signed and dated Research COI forms and a signed
and dated CV
Frequently Asked
Questions

Do I need to get IRB approval even if I’m just handing out the survey
away from my institution?


My IRB is notorious for taking a long time and making the process
difficult. Is it possible to use Beaumont Hospital’s IRB?


Probably not. You can check with your IRB or Research Department to see if they
would defer to Beaumont’s IRB but in most cases they will want to conduct their own
review.
My IRB charges a fee for review. Are there any funds to help me with
this?

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Yes. Even though there is really no risk to subjects, the studies involve minors which
triggers a mandatory IRB review
Not at this time. We are hopeful that we may get funds for this purpose from the STOP
Sports Injury Campaign at some point in the future. Other sites have had success with
getting the fee waived by describing the nature of the study and the sponsor (not-forprofit medical professional society)
I don’t have any research support and I’ve never completed IRB forms.
Is there any assistance available?

Yes. Just email me the required forms for your institution or the link to download the
forms. I can complete most of the items for you and send them back to you to do the
rest. Depending on my schedule, it may take a few weeks to get them back to you.
www.stopsportsinjuries.org
Sports Tips
Community Presentation
PowerPoint
Understanding & Managing
Relationship
Between
Throwing Mechanics &
Injury
John Albright, MD
University of Iowa
Perspectives on Risk
Factors
 “Every pitcher is the same”
 Pitch count
 Pitch speed
 Breaking ball count
 “Some individuals at greater risk”
 Anatomical variations ( Mayo Cl)
 Mechanism of delivery ( SDCH)
Hypothesis: Main Risk
Factor
Clinical Study of Baseball
Pitchers:
Throwing Arm Injury vs.
Method of Delivery
J Albright, P Jokl, R Shaw, J Albright
AJSM 1978
Robert Shaw
“How to last longest in the Major
Leagues”
Throw in downward plane
Faster
Less effort
Never miss inside-outside
Only miss high-low
Curve drops
Classic Outfielder’s
Pattern
(maximum speed & distance)
 “Long arm” delivery
 throws in “downward plane”
 ball high above head
 scapula/arm vertical to ground
 elbow extended (long lever
arm)
 minimum force on ligaments
 triceps muscle enhancement
 “Effortless” arm 1st (no whip)
Classic Infielder’s Pattern
(quickest ball release time)
 “Short arm” delivery
 elbow flexed (short lever
arm)
 arm abducted 90 °
 whiplash mechanism
 body first (“opens up”)
 scapular entrapment
 Maximum force on ligaments
 shoulder
 elbow
Materials
 109 little league
 18 college
Methods
 Slow motion videos
 2 views
 Questionnaire
 Physical exam
 swelling
 tenderness
 limited motion
Symptoms
Little League College
Frequency
44%
61%
Location
Elbow
Shoulder
Elbow
Mechanics of Delivery vs
Symptoms
All Pitchers
Form
Symptoms %
Poor (1+2)
73%
Good (4+5)
21%
Change of Pitching Form
 8 changed form on own
 5 changed form with
coaching
 All improved symptoms
Conclusions
 Arm Pain related to pitching form
 Poor form related to “whipping action”
 short arm delivery
 rushing
 opening lead shoulder
 lifting back foot too soon
Phase 1: Identifying the
problem
Identify magnitude of problem
 1975 study vs. 2010
Identify “blue chip" volunteers
initial data collection
Phase 2 participation
Phase 2: Pilot study
Step 1: validate 2 camera screening
Compare 2 to 6 camera system
10 Injured vs. Controls
Multiple test sites
Phase 2: Pilot study
Step 2: biomechanics lab correlation
of kinetics to Shaw-Albright
classification system
Can we easily ID very bad form that will
cause injury?
Who needs sophisticated lab evaluation?
Effects of Sequential Body Motion
on Elbow Valgus Loading during
Baseball Pitching
Arnel Aguinaldo, MA, ATC
Henry Chambers, MD
Center for Human Performance, San Diego, CA
Childrens Specialists of San Diego
Purpose
To determine which parameters most influence
valgus loading @ elbow
MLB Study Results
 higher valgus load in pitchers who initiated
trunk rotation before front foot contact:
Pre-Foot Contact
(N=34)
Post-Foot Contact
(N=35)
Valgus Load (N)
(p = .01)
282 ± 136
187 ± 153
Phase 2: Pilot study
Step 2a: Development of “Dick
Tracey” wristwatch (accelerometer)
Gill (MGH)55
Phase 3: Pilot study
AOSSM membership office based
2 camera video study
final classiciation?
Screen to biomechanics lab?
examination
100 Injurd vs. controls
Phase 4: NIH proposal
 This NIH field study will require that all
pitchers on every team studied will need to be
entered into the study prior to the beginning
of the season.
 This will be a prospective random block
selection intervention study.
 By the end of the study we will have
established a means of reduction of 50-75%
of throwing related upper extremity injuries in
youth baseball.
Phase 4: NIH proposal
 Those pitchers with poor mechanics
(therefore high risk of UE injury) will be
identified
Phase 4: NIH proposal
 Instructors will be assigned randomly to
teams to teach proper mechanics to the high
risk group
 No pitchers on the selected teams will be
allowed to pitch until they have demonstrated
proper form
 All pitchers will be removed from the mound
whenever their gyroscope data indicates they
have changed their mechanics to fall into the
high-risk pattern of throwing.