Biomechanics and the Youth Pitching Injury Epidemic

More than two million youth baseball players will take the field this spring in cities across America, from Ojai, California, to Buffalo, New York. But as those children enjoy the game, the onus on parents and coaches to insure their present and future health will be of particular urgency.

Since the mid-1990s, there has been an alarming uptick in pitching-related arm injuries in baseball, and in treatments such as "Tommy John" surgery—the procedure to reconstruct the torn ulnar collateral ligament (UCL) in a person's elbow. The surgery gets its name from the Los Angeles Dodgers pitcher who first underwent it in 1974 when he was 31 years old, and was pioneered by former Dodgers orthopedic surgeon Frank Jobe.

Today, the procedure is no longer the near-exclusive province of professional baseball players.

From 1988 to 1994, just seven ulnar collateral ligament reconstructions (UCLR) were performed on pitchers ages 10-19. Since then, that metric has spiked dramatically; in 2011 alone, there were 110 UCLR patients under 20 years old, which made up 67 percent of all people undergoing the procedure that year.

Youth and high school pitchers—not major leaguers—are the fastest growing UCLR patient category. Now some companies are trying to bring the biometric technology used by the pros, like wearables and motion capture, to young players hoping to prevent the same injuries.

Rick Peterson, the Baltimore Orioles' director of pitching development and founder of a biomechanics-based pitching program called 3P Sports, has long believed the catalyst for injury is at the earliest stages of pitchers' careers.

"Such a high percentage of young pitchers already have micro-tears in their elbows by the time they are drafted," said Peterson, a veteran coach of 34 years who is credited with the development of former Oakland Athletics aces Tim Hudson, Barry Zito, and Mark Mulder. "So why are all of these pitchers getting hurt professionally? Well, because the tread on the tires is already halfway worn out by the time we sign them."

This is not just an anecdotal theory.

Dr. Glenn Fleisig, a PhD in biomechanics and the research director of the nonprofit American Sports Medicine Institute (ASMI), has documented the relationship between high pitch counts and an increased risk of injuries in young pitchers. In a 2011 study published in The American Journal of Sports Medicine, Fleisig monitored a group of 481 pitchers for a decade, starting when they were around 10 years old. The paper concluded that those who pitched 100 or more innings in a calendar year were "3.5 times more likely to be injured."

Surpassing the 100-inning mark is now easier than ever as baseball, traditionally played in the spring and to a lesser extent during the summer, has morphed into a year-round purusit for youth and high school athletes. Fleisig believes the rise of Tommy John surgery among young pitchers is due to extreme overuse, not simply the popularization of the procedure's talismanic faculties, which typically include a return to pre-injury aptitude after 12 to 16 months recovery time.

"The passionate parent was not invented in the mid-1990s," Fleisig said. "But what changed—within American culture—was the availability and encouragement for kids to specialize in one sport and play it year-round."

Today, youth baseball has year-round leagues, travel teams, showcases and indoor instructional facilities all pushing unremitting play and training as a path to next-level stardom, or at least a college scholarship. These impulses have been buoyed by a wider interest in the benefits of early specialization. Dr. K. Anders Ericsson postulated in his 1993 paper for the Psychological Review that "deliberate practice" in early childhood is a veritable path to any "domain of expertise." Building on Ericsson's work, author Malcolm Gladwell proposed the "10,000 Hour Rule"—the theory that 10,000 hours of practice is necessary to master a given skill—in his 2008 best-selling book Outliers. (The purported rule has since taken a beating in author David Epstein's The Sports Gene and among dissenting researchers).

Applying this thinking to sports, and especially to developing baseball pitchers, can border on physical abuse, as shown by the work of researchers like Fleisig. And specialization is not worth the angst for most young players: only 0.5 percent of high school baseball players graduate to the major leagues, per a 2013 National Collegiate Athletic Association (NCAA) study; slightly more will play in college (about 6.8 percent of high school seniors), but of those, fewer than one in ten will go on to be drafted by a MLB team.

"The ignorance of parents and coaches is almost laughable, but it's not—there's nothing funny about it," said Peterson. "And there's nothing that indicates if you're a good pitcher from ages 10-14 that would translate into your late-teens or early-20s. It's a myth."

Based on the research of Fleisig and others, Major League Baseball and USA Baseball launched Pitch Smart in November 2014, which champions age-appropriate guidelines for pitchers, limiting pitch counts and encouraging rest. Some guidelines are overt, like the suggestion that pitchers aged 9-12 should "properly warm up before pitching." Others, like one mandating kids "take at least four months off from throwing every year, with at least 2-3 of those months being continuous," have the potential to inhibit abuse.

"The majority of youth organizations have opted in on the Pitch Smart program guidelines and even more are working with us on educating the general public," said Rick Riccobono, USA Baseball's Chief Development Officer. "We've made significant headway in the last few months in working with the National Federation of High Schools as well as with many individual state associations on tightening up their regulations when it comes to pitcher use."

The states of Colorado, Arizona, and Texas all confirmed with Riccobono they will adopt Pitch Smart's guidelines between this year and next.

A rubric only goes so far, however, and pitching-related injuries have not abated. Many see bringing biomechanics—the application and mechanics of how people move—into homes and schools across America as a necessary next step. Several companies have developed technology aimed at making individualized biomechanical analysis more accessible to the masses.

Confronted with an increase in injuries of their own, professional teams already have been flocking to companies like Kitman Labs, which record and track all kinds of information about players: pitch volume, gym workouts, PITCHf/x—"any data that tells us about this person," said Stephen Smith, Kitman's founder. Kitman then analyzes this data to find potential areas for improvement and injury prevention.

"Certain aspects of mechanics—and correcting mechanics—are impossible to see by the eye, so you need [specialized] computers and cameras to take measurements," said Fleisig. "An example of a flaw you cannot see by eye is the timing of when you rotate your pelvis compared to when you rotate your upper trunk. An elite pitcher will have a slight delay—a fraction of a second—between when he rotates his pelvis to make his bellybutton face forward, to when he rotates his upper chest to face forward. I can't and I don't know anyone who can see when the maximum velocity of those two body parts are by eye."

Motus Global, founded in 2010, is geared toward commercializing biomechanical analysis products for the sports world. The company, which Fleisig is a board member of, believes overuse is the culprit to pitching-related arm injuries, at any level.

"Many pitchers, when they come to us, are already damaged goods," said Ben Hanson, Motus' vice-president and CTO. "Motus saw this research trend and the need for the data. So we launched a product called mTHROW in 2014. Its sole goal was to measure workload on the UCL."

Last spring, 27 MLB teams used the beta device, a "smart" sleeve a player slips over his or her elbow; the AP reported this week that MLB has approved the use of the sleeve during games. Motus also debuted a commercial version of the technology in March called motusBASEBALL, which automatically monitors workloads in real-time, collects data, and signals "red flags," like fatigue. It retails for $150 on the company's website.

"Motus' technology is not just spitting out the acceleration of your elbow—it's actually using biomechanics equations to calculate the force on your elbow," said Fleisig. "Let's say you have two pitchers on a team and they both throw 65 miles-per-hour. And they both throw 70 pitches [in a game] and they go home and one kid says, 'Hey, my elbow hurts.' Wouldn't it be nice to know that one kid probably put more force on his arm per throw? Motus gives you that—the forces that are relevant to injury."

Fleisig also reports that companies are "racing" to democratize exorbitantly expensive motion capture technology for smartphones and tablets. Soon, an iPhone could turn a living room into miniature biomechanics lab.

Ultimately, though, it would fall on parents and coaches—who may only have high school educations, not years of medical training—to help kids apply biomechanical analysis results. This, rather than accessibility, may be the real hurdle. Even Peterson was initially stymied by the science, which Fleisig introduced to him in 1989. Peterson was a neophyte pitching coach with the Double-A Birmingham Barons; Fleisig had been working at the nearby American Sports Medicine Institute since its founding in 1987.

"Dr. Fleisig would come in and say, 'All right, Rick, [the pitcher's] stride length is too short, the bend of the knee is too firm at foot contact, it's collapsing his ball release, and the hip rotation velocity is only 400 degrees per second,'" Peterson recalled. "And I would say, 'Wow, really, Glenn. What the hell does that mean?'"

Peterson stayed in Birmingham until 1991, where he was able to gain a firm grasp on biomechanics before it had entered the baseball world.

"I was constantly in that [ASMI] lab," he said. "And then there was a moment where the apple fell off the tree, as if to say, 'This is gravity.' But then the next emotion that hit me was, 'Oh my God, I'm a fraud.' I had been teaching pitching for all these years, but I had no idea what was scientifically happening with a pitcher's delivery until my exposure to biomechanics."

But many amateur coaches are impervious to the effects of high pitch volume; Peterson's past attempts to introduce 3P Sports to popular instructional facilities were often rebuffed.

"A lot of these coaches actually believe they know more about pitching than I do," Peterson said. "They see kids as clients, not as developing humans."

Biomechanics isn't yet pervasive within collegiate and professional baseball, let alone youth and high school leagues. Yet to those like Dr. Fleisig who have labored to put biomechanics at the forefront of injury prevention, even gradual progress is revolutionary. He is optimistic that athletes who do not have access to world-class trainers and facilities can benefit.

"Widespread biomechanics is not only possible, but I think it's likely," said Fleisig. "You can educate to help people make better decisions. And the use of biomechanics is two-fold: one is to avoid injury, but the other is to improve your performance. Optimizing your mechanics has both advantages. And performance sells."

For Peterson, who endured a continuum of arm-related injuries as a former college and then minor league pitcher, it cannot have come a moment too soon.

"When I look at my life's work, I think back when I once pitched a complete game for Gulf Coast Junior College: I struck out 15, walked seven and gave up six hits. I had 13 guys on base," he says. "I had to throw every bit of 200 pitches. The next day, we got into an extra-inning game, and the coach says to me, 'Rick, we need you to pitch the 10th inning.' I warm up and my arm is not feeling so hot. I come into the game and get the first guy out. Then I throw a pitch to the next hitter, stepped off the mound, and said to myself, 'That didn't feel so hot.' I threw the next pitch, grabbed my shoulder, walked off the mound, and was never, ever the same."

Peterson added: "But that's why I do what I do. That's why I'm so passionate about protecting these kids' arms. I experienced this. I know this."