(
Received February 22; revision accepted for publication August 16, 1971.)ADDRESS FOR REPRINTS: (J.S.T.) St. Christopher’s Hospital far Children, 2600 North Lawrence Street,
Philadelphia, Pennsylvania 19133.
PEDIATRICS, Vol. 49, No. 2, February 1972
267
THE
EFFECT
OF
COMPETITIVE
PITCHING
ON
THE
SHOULDERS
AND
ELBOWS
OF
PREADOLESCENT
BASEBALL
PLAYERS
Joseph S. Torg, M.D., Howard Pollack, M.D., and Paul Sweterlitsch, M.D.
From the Department of Orthopaedic Surgery, Temple University Health Sciences Center, Department of Radiology, Episcopal Ho;pital, Philadelphia, Pennsylvania, and Department of Surgery, Secticm of
Orthopaedic Surgery, Abington Memorial Hospital, Abington, Pennsylvania
ABSTRACT. With the advent of Little League Baseball there has developed an awareness of the adverse effect that excessive pitching can have on
the growth areas about the shoulder and elbow of
the preadolescents. The terms “Little Leaguer’s
Shoulder” and “Little Leaguer’s Elbow” describe
distinct clinical entities. In addition to reviewing these problems, an attempt has been made to identify their cause. Specifically, clinical and
radiological observations made on a group of 49 pre-adolescent pitchers who participated in a bow-com-petition, recreational baseball program are
report-ed. Although the data are not conclusive, we believe our observations indicate that the preadolescent should avoid pitching in an intensely competitive situation. Pediatric;, 49:267, 1972, LITTLE LEA-GUER’S SHOULDER AND ELBOW, BASEBALL PITCHING,
EPIPHYSEAL INJURIES.
F
decades American youth haveplayed the game of baseball guided by their own desires and physical abilities. With the advent of the Little Leagues an-other element, adult supervision, has been added. With this adult supervision and
reg-ulation have been associated, in most in-stances, repetitious and demanding prac-tice, unwarranted pressure to win, demands for maximum effort and perfon-mance, and the tendency to treat young-sters, who are immature both physically and emotionally, as adults. Subsequently, there has also developed an awareness of
the potentially detrimental effects that
ex-cessive pitching in such a situation can
have on the growth areas about the
shoul-den and elbow. Those responsible for the care of preadolescent baseball pitchers should be aware of these problems. The
purpose of this paper is to review the
litera-tune dealing with Little Leaguer’s Shoulder and Little Leaguer’s Elbow, and present
the findings of a clinical and roentgeno-graphic study performed on 49 pitchers ranging in age from 9 to 18 years who have
participated in the Lighthouse Boys’ Club
baseball program in Philadelphia.
The term “Little Leaguer’s Shoulder” was
coined by Dotter1 to describe a case which he believed represented a fracture of the
proximal humeral epiphyseal plate due to baseball pitching. His patient experienced the onset of a sharp pain in his right shoul-den with every attempt to throw a baseball
while pitching in a Little League game. This persisted for 3% weeks, at which time roentgenograms demonstrated “widening of the radiolucent line of the epiphyseal carti-lage of the proximal humerus with some os-teoporosis of the proximal quarter inch of
the diaphysis adjacent to the line.” The pa-tient responded to conservative treatment. Subsequently, Adams2 reported what he considers to be osteochondrosis of the prox-imal humeral epiphysis in five boy baseball
pitchers.
We have cared for a 12-year-old pitcher who experienced the onset of persistent shoulder pain following a “tryout” to make a Little League team. Roentgenograms ob-tamed 2 months later demonstrated
changes similar to those described by Dot-ten,’ Adams,2 and Gyepes3
(
Fig. 1)
. Allre-sponded to simply refraining from pitching until the proximal humeral epiphyseal line
closed.
“Lit-I
FIG. 1. AP roentgenograms of the shoulder of a
12-year-old Little League pitcher. He had experi-enced onset of shoulder pain 2 months prior while
pitching in “tryout” to make the team. The radio-lucent hand involving the metaphysis of the
hu-meriis adjacent to the epiphvseal olate is abnormal
and has becn described by Dotter in his original description of Little Leaguer’s Shoulder.
tie League Elbow” to describe clinical and roentgcnographic findings seen in the
pitch-ing elbows of two Little League pitchers,
ages 11 and 12 years, following episodes of
maximum effort. Each had pain, tender-ness, and swcUing over the involved medial epicondyle that precluded any further pitching. In both instances, roentgenograms demonstrated separation and fragmentation
of the medial epicondylar apophysis with loss of adjacent fascial planes. More
re-cently, Adams reported a study of
trau-niatic changes in the elbow joints of boy baseball players. Prompted by the
fre-qucncy of elbow problems with
roentgeno-graphic changes among pitchers, he studied both elbows of 162 subjects in the 9 to 14
year age group. In this study group there
were 80 pitchers, 47 nonpitchers, and 35 nonplayers. Among the 80 pitchers, he ob-served fragmentation of the medial epicon-dylar apophysis
(
Fig. 2)
in 39, and osteo-chondrosis of the capitulum humeri and head of the radius in six(
Fig. 3).In that medial epicondylar apophysitis and osteochondrosis of the capitulum had
not been reported prior to the advent of or-ganized baseball for youngsters, Adams
concluded that these conditions resulted
froni a competitive situation that subjected
the young pitchers’ elbows to excessive
re-petitious trauma. He further suggested that
in order to prevent abusing the arms of the skeletally immature, the following guide-lines be followed :
(
1)
Discourageyoung-sters from practicing pitching at home he-fore, during, and after the season.
(
2)
Abol-ish curve ball throwing at this age. (3)
Shorten the playing season, especially in Southern California, where it is overly pro-longed.
(
4)
Restrict pitchers to two innings per game until the epiphyses are corn-pletely closed. (5) Divide Little Leag’e into two groups-one for 9- and 10-year-olds, the other for 11- and 12-year-olds.The extremely high incidence of
abnor-malities reported to occur in the should’rs and elbows of Little League pitchers dc-niand further study, particularly with re-gard to prevention. The recommendations of Adams, although admittedly sound, arc conjectural and do not obviate the need f r consideration of the possible roles of other factors. Thus, an attempt has been made to study the effects of pitching on the arms of preadolescent participants in the Light-house Boys’ Club baseball program.
The Lighthouse Boys’ Club is an
Philadelphia. A spring baseball program is
conducted for 450 club members who range from 9 to 18 years of age. The program is
run by a full-time salaried director assisted
by community volunteers. The program is organized to encourage participation and recreation rather than ferment intense
corn-petition. Thirty teams of 15 players each
are divided into four leagues according to age, i.e., 9 to 10, 11 to 12, 13 to 14, and 15 to 18 years. At the beginning of each season, the teams are arbitrarily chosen from the
pool of members. Each team plays 20
ganies, and all team players must play at
least four and one half innings of every game. Regarding rules governing pitching, each pitcher may pitch seven innings each
week. Curve ball throwing is perrnitted.
FIG. 2. AP roentgenograms of the pitching elbow
of a 12-year-old Lighthouse Boys’ Club player. There has been an avulsion of a fragment of the
medial epicondvle. In addition to fragmentation
and acceleration of growth of the medial
apophy-sis, Adams has reported instances where complete separation has occurred in Little League players.
At the conclusion of the 1970 Lighthouse Boys’ Club baseball program, 49 pitchers ranging from 9 to 18 years of age were
cx-ammed and roentgenograms of both elbows and both shoulders obtained. In addition,
information was obtained regarding symp-toms referable to the elbow and shoulder,
practice habits, carve ball throwing, pitch-ing for other teams, and whether arms had been previously injured. The rcsults of this
study are tabulated in Tab1e I.
Examination of the data reveals that one or
more episodes of pain were experienced as
FIG. 3. AP roentgenograms of the pitching elbow
of a 12-year-old Little League player. The
radio-lu(ent area involving the capitulum of th
liii-merus associated with pain and limitation of joint
motion 6 months following intensive pitching
ef-fort is compatible with the diagnosis of
Player Ae
Pain Practice
Other Teams
Physical Fndings
Roe,itgenojram
Findings }‘ears
Pikhin Shoulder Elbow Other home SeasonOff
Curve Ball Throw-ing + -+
-- - Prominent med.
epicondyle ileg neg Fragmented med. epi-S 4 5 6 .5 3 4 5 4 6 9 6 4 10 5 5 8 5 neg neg neg neg iieg neg neg iieg neg neg neg neg neg neg neg neg neg neg iieg neg neg neg neg neg tieg neg neg neg neg 270 TABLE I
CLINICAL AND ROENTGENOGRAPHIC DATA
1. 1.11. 9
. KM. 9
3. M.K. 10
4. w..s. 10
5. CII. In
6. P.V. 10
7. MR. 10
8. B.W. 10
9. W.M. 10
10. J.T. 10
11. G.S. 10
. J.c. 10
Is. iF. 11
14. T.W. 11
15. TB. 11
16. T.L. 1
17. AM. l
18. J.C. 1
19. W.N. I
0. M.C. H
21. J.G. H
2Q. D.G. H
23. R.G. H
4. M.M. 13
25. M.M. 13
26. R.R. 13
27. D.S. 13
28. E.G. 13
9. R.S. 13
30. R.S. 13
31. D.M. 13
H. DI.. 14
33. F.S. 14
34. T.R. 14
35. M.F. 14
36. J.S. 14
37. W.M. 14
38. ES. 15
39. JO. 15
40. G.W. 16
41. AG. 16
4. MM. 16
43. J.P. 16
44. J.M. 17
45. J.D. 17
46. RD. 17
47. TB. 17
48. MT. 17
49. \v.P. 18
2 + - - +
-1 + - - +
-‘1 - + - +
-1 - - - +
-2 - + - + +
I - - biceps + +
- + - +
-- - - +
-S - - - +
-- + -
-- + - +
-3 + - - + +
4 - - - +
-- - - + +
- - biceps +
-1 - - - - +
1 - - - +
-S - - - + +
1 - - - +
-- - scapular + +
+ - - + +
- - - + +
- - biceps + +
+ - - + +
+ - - +
-+ - -
-+ - - + +
+ - - + +
- - biceps + +
- + - +
-- + - + +
+ - - + +
- - triceps -
-+ - - +
-+ - - + +
- + -
-- - biceps +
-+ - - ± +
- + -
-- - biceps -
-- + - +
-- + - +
-- + - +
-- + -
-+ + - + +
+ - neg
- - Swelling-apparent valgus iteg
- - Apparent valgus iieg
+ - neg
+ + neg
+ - neg
- - neg neg
- - tieg neg
- - iieg neg
+ - neg
+ - Prominent med. epicondyle neg
+ - neg
- - Swelling-tenderness tieg
Prominent med. epicondyle
+ - Apparent valgus neg
+ - Tenderness-apparent valgus neg
+ - Apparent valgus neg
+ - Prominent med . Fragmented
epicondyle med.
epi-+
-- - neg
- - Apparent valgus
+
-+
-+ - Tenderness-swelling Apparent valgus
+ +
+ - Swelling-apparent valgus
+ +
+ - Apparent valgus
5’ elbow flexion contracture
+ - Apparent valgus
+ - Apparent valgus
+
-+
-+
-+ - Apparent valgus
- - Swelling-tenderness
Apparent valgus
+ +
+ - Apparent valgus
+ - Apparent valgus
+ +
- - neg
+ + Apparent valgus
7’ elbow flexion contracture
+
-+
-+ + Apparent valgus
+
-+ + Apparent valgul
+
-condyle
follows; shoulder = 13, elbow 13,
shoul-den and elbow = 1, biceps 6, triceps
6, and scapular = 1. Thus 35 of the 49
sub-jects, or
70%
admitted to having had pain.In no instance, however, did pain cause
anyone to seek medical attention on prevent further participation. When considering that any vigorous physical activity may be associated with muscular discomfort, such complaints are not considered significant
unless accompanied by disability. In no in-stance did any of our subjects admit to any
disability.
Forty, or 80% of the boys examined had practiced pitching either at home and/or during the off season. Also, 39, on 78%
ad-mitted to throwing curve balls. Seven of the forty-nine had played for school teams con-currently with their activities in the
Light-house Boys’ Club program.
Regarding positive physical findings, 18 pitchers manifested what might be best de-scnibed as apparent valgus attitude at the elbow. Of these, six also presented with tenderness in this area. In all instances, this was attributed to hypentrophy of the mus-cle mass of the flexor-pnonaton group in the forearm in proximity to them origin from
the medial humeral epicondyle and proxi-mal ulna. Considered significant, however,
were findings of actual prominence of the medial epicondyle in two subjects, and 5#{176}
and 7#{176}elbow flexion contractures in two others, respectively. The former were ex-plained by roentgenographic findings to be described; the latter as being due to ante-rior capsular sprain and/or muscular strain secondary to the excessive stresses of pitch-ing.
Roentgenognaphic examinations were performed on the shoulders and elbows of 44 of the 49 youngsters. In no instance were abnormalities detected in any of the shoul-dens. Three players had what appeared to be an asymmetrical enlargement of the me-dial epicondylan apophysis of their pitching arm. In that asymmetrical development of these centers is not abnormal, these findings are not considered significant. However, the
two boys that had clinically prominent
me-dial epicondyles demonstrated fragmenta-tion of this center roentgenognaphically. Al-though both had pitched for only one season and denied elbow pain, the radio-graphic changes are attributed to their
pitching.
When compared with the pathologic changes demonstrated by Adams in his
study of Little Leaguers’, our findings are
relatively few. This is particularly signifi-cant considering that the Lighthouse pro-gram does not follow Adams’ recommenda-tions. That is, they allow a boy to pitch seven innings rather than two in one game.
Curve ball pitching is not restricted. Also, most of the Lighthouse boys practice pitch-ing at home during and after the season.
What then is the difference between pitching in the Little Leagues as compared
to the Lighthouse program? Having consid-ered all factors, we believe that the major difference is the circumstances under which the two groups participate. Specifically, Lit-tle Leaguers must compete to make the team, must compete to play in each game, and are subjected to intense pressures to
win by adult coaches and spectators. On
the other hand, the Lighthouse Boys’ Club members are automatically assigned to a
team and must play at least three and one half innings of each game by Club negula-tion. The general attitude is one of
partici-pation for the sake of recreation rather than competition.
We recognize that the data and
observa-tions presented in this paper are not conclu-sive. We believe, however, that they do suggest that to subject a preadolescent pitcher to an intensely competitive situation
is not in his best interest from the
stand-point of healthy skeletal development and maturation.
REFERENCES
1. Dotter, W. E. : Little leaguer’s shoulder-A
frac-ture of the proximal epiphyseal cartilage of
the humerus due to baseball pitching.
Guth-ne Clinic Bull., 23:68, 1953.
272
boy baseball pitchers. California Med., 105: 22, 1966.
3. Gyepes, M. T., Newbem, D. H., and
Neuhau-ser, E. : Metaphyseal and physeal injuries in children with spina bifida and meningomyelo-celes. Amer. J. Roent., 95:176, 1965.
4. Brodgen, B. G., and Crow, N. E.: Little
lea-guer’s elbow. Amer. J. Roent., 83:671, 1960. 5. Adams, J. E. : Injury to the throwing arm. A
study of traumatic changes in the elbow joint
of boy baseball players. California Med., 102:
127, 1965.
6. Adams, J. E. : Bone injuries in very young
