Throwing Injuries in the Young Athlete – PediaCast 513

Show Notes


  • The Sports Medicine Team visits the studio as we explore throwing injuries. From Little League to Major League, shoulder and elbow injuries are common in those who pitch and throw. We consider diagnosis, management and prevention. We hope you can join us!


  • Throwing and Pitching Injuries




Announcer 1: This is PediaCast.




Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.


Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from Nationwide Children's Hospital. We're in Columbus, Ohio.


It's Episode 513 for March 8th, 2022. We're calling this one "Throwing Injuries in the Young Athlete". I want to welcome all of you to the program.


So spring is finally around the corner here in the United States. And with spring comes the beginning of baseball season for millions of young athletes, from Little League to high school, club teams in college. And baseball season also means the arrival of injuries of many sorts and flavors. After all, baseball did invent the Injured List, originally the Disabled List and they renamed it the Injured List in 2019.




Among the common injuries of baseball are those associated with throwing and pitching. And these tend to be injuries involving the shoulder and the elbow. Things like rotator cuff problems, you've probably heard of those. Shoulder dislocations and instability, Little League elbow, tendon and ligament injuries and elbow fracture and dislocations and some other conditions with fairly long complicated sounding names that we'll break down for you and try to explain as we move along.


We'll talk about how throwing injuries are diagnosed and treated and rehabilitated and prevented, all important things. And to help us with that conversation, we have two terrific guests joining us this week. Dr. Tom Pommering is chief of Sports Medicine at Nationwide Children's Hospital and Herman Hundley is a certified athletic trainer, also from Nationwide Children's.




They will be here shortly, but first, I did want to say welcome to the hospital formerly known as Mercy Health Children's Hospital in Toledo. They joined our hospital family this month and they're now known by a new name, Nationwide Children's Hospital-Toledo. So a very warm welcome to the physicians, staff, patients, families and community of Toledo, Ohio. We're very happy to have you along as we journey together down the road of pediatric health and wellness.


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So let's take a quick break. We'll get Dr. Tom Pommering and Herman Hundley  connected to the studio. And then, we will be back as we explore throwing injuries in young athletes. It's coming up right after this.






Dr. Mike Patrick: Dr. Tom Pommering is chief of Sports Medicine at Nationwide Children's Hospital and an associate professor of Pediatrics at the Ohio State University College of Medicine. Herman Hundley is a certified and licensed athletic trainer at Nationwide Children's. Each have years of experience diagnosing, treating and preventing throwing injuries which are common in athletes of every age, from Little League to the Major League and everything in between.


That's what they're here to talk about, throwing injuries in young athletes. But first, let's give a warm PediaCast welcome to our guests, Dr. Tom Pommering and Herm Hundley. Thank you both so much for being here today.




Dr. Thomas Pommering: Hey, Mike, great to be here. Thanks for having us.


Herman Hundley: Thanks for having me, Mike. This is something we're both pretty passionate about and we're happy to share some information with the public.


Dr. Mike Patrick: Yeah, we're really glad that you both are here.


Tom, let's start with you. Throwing injuries are actually pretty common in student athletes. And over two million children participate in Little League activities alone. So just the sheer volume makes this pretty common. But are there factors that makes throwing injuries common in kids?


Dr. Thomas Pommering: Yeah, I think probably the two biggest things are going to be throwing too much too fast, too hard and then for too long. And then the other thing, which is one of the reasons we have experts like Herm on our team is having poor throwing mechanics.


Dr. Mike Patrick: And kids also have these growth plates, right, that make them a little bit different than adults in terms of injuries? Speak to those.


Dr. Thomas Pommering: Yeah, for sure, kids have growth plate in the top of their shoulder, their humerus. And they have actually six growth plates around their elbows. So until those become mature and hard enough, they are more vulnerable to the stresses of throwing actually than the ligaments and tendons.




Dr. Mike Patrick: And so that's kind of the weak point of the shoulder and elbow, those growth plates. And then, like you said, there's a lot of repetitive motion with throwing. There's high energy forces. And so, all that is kind of a bad combination in terms of the potential for injuries.


I also want to point out right now. We are talking primarily about baseball and softball pitchers and throwers, but tennis players and golfers can have similar injuries, right?


Dr. Thomas Pommering: Yeah, absolutely. People forget those throwing motions. And also, though football is not a year-round sports, if you're a good thrower in football, you're also probably a good thrower for baseball. So definitely, those other sports mimic the throwing motion.


Dr. Mike Patrick: Yeah, how about bowling?


Dr. Thomas Pommering: Probably not? But they have their own unique injuries.




Dr. Mike Patrick: I don't know, I guess you don't really throw the ball but it is repetitive motion. And there's some high energy with the weight of the ball.




All right, so Herm, we talked about those growth plates in kids. What do you see in terms of throwing injuries in children and teens and how are those different than in adults?


Herman Hundley: Typically we see a lot of the same injuries, or similar types of injuries in children and adults but the biggest difference is with our young athletes, those growth plates. So when we see damage or alterations to growth plates, inflammation to those growth plates, that's what we would call Little League shoulder for instance, or Little League elbow. Those are predominantly what we see in our younger athletes until they are physically matured.


Injuries tend to lend themselves to the weakest point in the chain and weakest point in that area. So the stress that's put on it by throwing places a tremendous amount of stress in the elbow and the shoulder. And typically, those growth plates are the weakest areas of growth and bone.


In children, we see injuries to the growth plate. As they get older and more mature, those injuries typically present themselves into the ligament structures of the shoulder and the elbow. So things like UCL sprains, labrum injuries and rotator cuff injuries and things like that in older athletes when they're more skeletally mature.




Dr. Mike Patrick: When a kid has an acute injury, so they're throwing and all of a sudden their elbow is hurting a lot, maybe there's swelling involved with the pain, that's not something they should necessary keep throwing through. They really ought to be evaluated, correct?


Dr. Thomas Pommering: Absolutely, and I think you have to remember the injuries to the growth plates can be just an inflammation of the growth plate. Or sometimes if the growth plate is weakened enough, it can be pulled away or bolts off. We really want to avoid that scenario because it complicates their treatment and sometimes even requires a surgery.


Dr. Mike Patrick: Yeah, it's one of those things where in adults, you have some swelling, it's likely to be soft tissue, injury. If there's a fracture, you're probably going to know it, unless it's a small subtle one.


But with kids and growth plate injuries, even if there's a mild growth plate injury, now that growth plate is weaker and if you continue to throw through that injury, you could really end up with a bigger injury, correct?




Dr. Thomas Pommering: Yeah, absolutely. Plus, it's just more downtime. If you can catch this early and address it, you don't have to miss a big part of your season.


Dr. Mike Patrick: Yeah, go ahead, Herm.


Herman Hundley: What I tell a lot of athletes is you shouldn't throw through pain. If your arm's hurting, you should stop and see somebody. When you have pain in your elbow or your shoulder, soreness is one thing when you're a little sore after and you should go fine the next day, that's perfectly normal. But when you're throwing and you're having pain, that's your body's way of telling you that you need to stop. Something's wrong. Something needs to be addressed, and that's when you need to seek out a physician.


Dr. Mike Patrick: And some kids don't want to do that because it might mean that they miss playing. But I guess if you take from the standpoint that if you are injured, of course, as you said, the injury could get worse and you're going to be out longer. But also, when you're injured and you have pain, your throwing mechanics aren't going to be exactly the same. You're going to be as accurate. You're not going to be able to throw it as hard.




And so, your performance is going to go down. And so sometimes that may be a way to motivate kids to actually stop playing and get help, so that they can be at their best performance.


Dr. Thomas Pommering: Yeah absolutely, that should be a sign for coaches and parents too. When kids start to lose their control and just start to kind of shake their arm a lot, things like that.


Dr. Mike Patrick: So let's focus in on the shoulder. Tom, what are some of the common injuries that we see in throwers that involve the shoulder?


Dr. Thomas Pommering: And again those younger throwers tend to have more of an injury to their growth plate atop of their shoulder. And that'll present with just sort of insidious pain. Again, all the things we've talked about, like loss of control or velocity.


And as they get older that growth plate becomes more solid and more stable. Those forces get transferred more into the rotator cuff muscles around the shoulder, where they get tendonitis.


Dr. Mike Patrick: Tell us more about the rotator cuff, I think a lot of people have heard rotator cuff and rotator cuff injuries. It's like one of those things that everybody has heard but what exactly is that?




Dr. Thomas Pommering: Yeah, so it actually comprises of four different muscles. Sometimes, people kind of use their rotator cuff, sort of collectively as one group. But they all support and stabilize the shoulder and keep it functioning, like keep it in a position that makes it the most functional. So, when your rotator cuff gets injured, your shoulder actually doesn't function the way it should. And that leads to even more injury.


Dr. Mike Patrick: You mentioned a sprain or a strain of tendons. Kind of walk us through, first of all, what is a tendon? And what is actually happening when there's a sprain or a strain? Or is there a difference between those terms?


Dr. Thomas Pommering: So tendons connect muscles to bone. And the tendons are relatively avascular. In other words, if you injure a muscle, it will bruise and bleed. But tendons don't really have a good blood supply. So when they get injured, it's actually harder for them to heal. And so again, there lies the importance of trying to catch these injuries early.


Dr. Mike Patrick: Yeah, really important. And when kids do have these injuries, who do you usually have them see? Should they go to their family doctor, sports medicine folks, athletic trainer? Herm, you have some ideas about this.




Herman Hundley: First and foremost, they need to see their physician. Whether it be their family doctor or sports medicine, we always recommend seeing a sports medicine physician, especially for sports medicine injuries. But usually, our physician refer our athletes to either a physical therapist or an athletic trainer.


And, usually, myself here at Children's, I do a lot of our throwing injuries and our throwing rehabs within our functional Rehab Department. We do a rehabilitation process and kind of get them working on a throwing mechanics sports and their return-to-play progression, with the gradual return to play, with emphasis on injury prevention and improving their mechanics.


Dr. Mike Patrick: Heading back to the shoulder for a moment, if you look up shoulder injuries in throwers, a lot of the stuff out there that you're going to find. Like the parent just Googles, "Hey, what's wrong with my kid's shoulder, their thrower?"

You're going to see a lot of things in the adult world like SLAP tears, for example, and SICK scapula syndrome, all sorts of things. Do you see much of that in kids or is it really mostly rotator cuff and tendonitis?




Dr. Thomas Pommering: Definitely the older throwers who have a lot of throwing volume under their belt. They're more experienced throwers. They have a lot of longevity in their shoulders, especially if they haven't been doing things the right way. We will see things like the SICK scapula syndrome, which really is probably is much an overuse related problem, whether mechanics or alter because they just have a tired shoulder or shoulder that's weak.


And then we do see some labral injuries in older athletes, especially again, if they've had history of knocking their shoulder out of joint that tends to injure the labrum or just if their throwing volumes are just way too high in year-round.  And another, I'll just say, kind of one good preventive tip, and this is based on good evidence, is that you cannot throw anywhere from… If you can take a two to four-month period off a year not throwing, your chances of needing a shoulder or elbow surgery go drastically down.




Dr. Mike Patrick: So you really need some rest at some point during the year, that's really important. And that can be tough because there's always these traveling sports. I guess in the middle of winter in Ohio, maybe it's a little bit easier to take that break. But if you're somewhere where it's warm all year round, than could be a real challenge.


Dr. Thomas Pommering: Yeah, for sure. And this evidence actually comes out of the south, where they do throw just about year-round. It's funny in the Midwest, we find ways to do things in the winter. So there's lots of indoor training facilities. So it isn't too hard for kids to train year-round. Again, if you can take a break or move to a different sport that doesn't involved throwing as much, that's often very helpful.


Dr. Mike Patrick: Let's move on down to the elbow. And Herm, this is going to be for you. What are some of the common injuries of the elbow that we see in young throwers?


Herman Hundley: Like we said before, first and foremost, it's probably going to be Little League elbow. We do see that, probably most frequently, out of everything, all the injuries to the elbow in the young athletes.




I'll say the big three are going to be Little League elbow, or medial epicondylitis, or osteochondral defects , things like that. And our throwers, those would probably be the bigger three or the most significant three that kind of take the most time to heal and recover from.


We also see things like muscle strain and tendonitis of the forearm muscles, tendonitis of the triceps and biceps. So we do see that at the elbow as well in our young athletes. And then as they get older, we tend to see a lot more of the inside of the elbow pain which will your flexor tendonitis, your medial epicondylitis, and also sometimes ACL sprains, where there will be going to be more significant injuries to the elbow.


Dr. Mike Patrick: We've been using some terminology that parents may not be used to hearing. And so I want to actually just slip back up to the shoulder really quick. Tom, you said labrum. The labrum is a piece of cartilage that deepens the socket of the shoulder, right? So that you think about the arm coming into the shoulder, it's a ball and socket joint. And the socket that the ball fits into the labrum is a cartilage cushion. Is that adequate explanation of that?




Dr. Thomas Pommering: Yeah, absolutely. We only use the analogy that the shoulder's like a golf ball on a tee. So the tee is the socket. It's not very big. And that's to allow the shoulder a really wide range of motions. So the cartilage or the labrum deepens that socket a little bit. But because of soft tissue, it is more prone to injury. It's not as strong as bone.


Dr. Mike Patrick: And then Herm, you had mentioned UCL. I've heard that a couple of times. What is the UCL?


Herman Hundley: So UCL is the ulnar collateral ligament. It's the ligament that attaches on the inside part of the elbow that attaches the upper arm to the lower forearm muscle, the ulna to the humerus. That is typically what most people think about when they hear the word Tommy John surgery. That is the ligament that's damaged or ruptured that requires Tommy John surgery.




So that's the one that's probably the most significant injury at the elbow in our throwers. Typically, we see it in older throwers, but we are seeing it in younger throwers as well, where they have those sprains early on and that's going to cause issues down the road.


Even with the rehab and things like that, with pitching and with throwing, that's going to continue to be a problem moving forward with sports specialization and things like that. That's why we're trying to get on the front end of it with our young throwers.


Dr. Mike Patrick: And then, you also mentioned, Little League elbow, what exactly is that?


Herman Hundley: So the Little League elbow is actually damage or inflammation of the growth plate at the inside of the elbow, right at the medial epicondyle. There is a growth plate there, inside of the elbow, same area where that Tommy John ligament or that UCL is. That growth plate can be inflamed, can be damaged by throwing. And that's typically what we see in our younger throwers, middle school and elementary school and sometimes early high school age.


Dr. Mike Patrick: What about fractures and dislocation? So actually breaks in bone itself or dislocations of a joint, do you see that very often in throwers?




Dr. Thomas Pommering: We don't see dislocations quite as much. But again, if you weaken one of those six growth plates around your elbow, you can't pull that away because it is attached to a really strong muscle and tendon that's constantly pulling in that growth plate. So if you overstress that growth plate, it can be popped off.


Dr. Mike Patrick: So again, another reason to take a rest and to pay attention to any pain in swelling and figure out what's going on and not throw through it and them damage things even more.


And then, some kids may have a bone cyst or something that they don't even know is there and the forces of throwing could break their humerus. But there's no way really to know that till it happens, unfortunately.


So Tom, what is the approach then for figuring out what is going on, because from the kid's standpoint and the family standpoint, "I'm a thrower and now, my shoulder has started to hurt maybe a week or two ago. And it's just getting worse. And that's interfering with my throwing." Same thing with the elbow.




What is your approach for the kid that comes in with pain associated with sports?


Dr. Thomas Pommering: Yeah, great question. I think that we've already touched on this. The first thing, the most important decision you have to make is to stop throwing through pain. So we can try to figure this out.


So patients come in to see us. Part of the workup is going to be to take a really good history, detailed history about their throwing practices. And we will use that as part of our prevention and education.


And then, second part is making a diagnosis, figuring out which structure has been injured. Patients will get an X-ray because we want to look at those growth plates. And then, once we make the diagnosis, we have a big discussion on how you got there, how not to be back there again, because we can make your injury get better.


If we don't change the practices that lead to an injury, you're going to be right back in the office again. And this is again where Herm and his team do such a great job with rehab and helping them improve their throwing mechanic, which almost always part of the problem.


Dr. Mike Patrick: Do you sometimes have an idea what's going on even before you get the X-ray, just based on our physical exam?




Dr. Thomas Pommering: Yeah, for sure, if we can reproduce the pain with some of the exam techniques or places that we push on, we get a pretty good idea of where to focus in on. And then, their history too is also important.


Dr. Mike Patrick: And when it started hurting, what they were doing and what makes it worse, what makes it better?


Dr. Thomas Pommering: Yeah, again, when you're asking an athlete about injury, you really asking sports-specific questions. So for throwers, we'll ask them, what positions they play otherwise, because a lot of times the pitchers are the most skilled athletes on the team. And they also shortstop or catcher or third, which are also high throwing volume positions.


We'll ask them if they know what their pitch counts are. People are counting. I like to ask them how fast they throw because if they can fire that up, "I throw a 75 miles an hour," then I know that someone has a radar gun around. And that won't encourage him to throw harder than normal.


And then, we'll ask him how soon into their throwing outings their hurt is getting worse. Does it hurt with other activities outside of throwing such as batting or everyday activities? So really just trying to kind of figure out how involved this is and how they got to where they are.




Dr. Mike Patrick: So all important that the history, the physical and then getting those X-rays. And then once you figure out what is happening, there's really two phases of treatment, right? The acute phase right after an injury happens and then the rehabilitation phase to get you back and ready to play again.


What about the acute treatment? I know it's going to depend a little bit based on exactly what is going on. But what are some general principles for treating injuries that involve muscles and tendons.


Dr. Thomas Pommering: So again, since these are usually overload injuries, the biggest part of the initial treatment is resting joint. So sometimes, we'll temporarily put them in a brace or sling. But for the most part, we let them keep using their joint, as long as it's not hurting with everyday activities. So resting, again, education.




And then, the other thing we do is let them do things that don't hurt their elbows. So for example, they can do some conditioning, some running and jogging and stretching, things like that. So they're completely out of their sport but we do want to protect the joint that hurts.


Dr. Mike Patrick: What about ice and heat? And which one is best?


Dr. Thomas Pommering: Yeah, age-old question. So I think the short answer is nobody knows, but here's what I tell patients. If there's any swelling and acute pain after an activity, I ask them to ice. Because if something has swelling, heat will actually make it swell more. So the only time I really have people use heat if they're just warming the area up and it's not acutely injured. And again, I don't know that there's a right or wrong answer but that's the general guide I give patients and families.


Dr. Mike Patrick: When we worked in the emergency department and the urgent care center, it's always RICE, Rest, Ice, Elevation and Compression. But really, the rest is probably the most important part, correct?




Dr. Thomas Pommering: Absolutely.


Dr. Mike Patrick: And the rest of it is really comfort measures. And then, of course, there's also pain medicine and non-steroidal anti-inflammatory drugs like ibuprofen, for example, that can help reduce swelling and help with pain that you can use as well. And then, what about the more significant injuries that involve the growth plates? What is the immediate treatment look like for those.


Dr. Thomas Pommering: Yeah, this is where rest is really essential because that growth plate has the ability to repair itself. But it won't if we keep stressing it. So that does involve a certain period of rest. Sometimes, that can really be the matter of even weeks.


Dr. Mike Patrick: Yeah, and if the growth plate is moved or coming away from the bone, then that could potentially require a surgery as well to put it back.


Dr. Thomas Pommering: Yeah, for sure. It depends on how far it's been pulled away and kids are pretty resilient. But again, we certainly don't want them being in that scenario if we can help it.


Dr. Mike Patrick: If they do have any kind of surgery and this may be a motivator for kids to, as they're out for a lot longer after a surgery, then if you catch this early and rest it, it can be months that they're off if they have to have a surgery on the growth plate, right?




Dr. Thomas Pommering: Yeah, absolutely. And the other thing is I think there's kind of a common misconception that maybe it's based on pop culture and movies that, "Oh, if you get a Tommy John surgery, you're going to come back even stronger." And it's just not true. In fact, certain percentage of folks who end up with a Tommy John surgery will never return to their previous level of throwing.


And that recovery for that surgery is about a year and sometimes longer. So we really kind of keep people out of that scenario if we can help it.


Dr. Mike Patrick: And so more reason that if your child has pain and they throw a lot, make sure that you see a sports medicine physician and get the right diagnosis.


So Herm, so we have the acute treatment of the injury, but usually, things are feeling better in seven to ten days, if it's a sprain or a strain. But you really lose a lot during that time and you can't just go immediately back to where you were, right? There's got to be a rehabilitation process. Tell us about that.




Herman Hundley: So piggybacking off what Dr. Pommering had said, the doctors will refer patients to us during that rest phase, so when they're resting from throwing so that we can start addressing other issues. So what we'll happen is they'll come to us and we will work on the elbow or the shoulder in terms of pain modulation, helping kind of improve their pain, control their swelling things like that.


While they're resting from throwing, there's still going to be pinch, will be hitting and running and fielding, as long as that's pain free. And during that time, we can work on range of emotion and flexibility of their lower body, core strengthening. We can start working on scapular stability and improving their shoulder strength while they're recovering and while their body is resting from those injuries.


And then, that really rolls into phase two, is once they are pain-free again, we can start to progress strength more and do some more weightlifting type activities, power exercises. We use a lot of medicine balls in our rehab, especially for our throwers, for rotational power and upper extremity power, things like that.




And that's when we would start to incorporate a soft toss, light throwing, maybe some first-base play. And then we will begin their progression. We will do a video analysis on their throwing motion, breakdown on mechanics. Kind of start working on some of those correctives.


Trying to clean up the mechanics a little bit to decrease the arm stress. And then during that time, they'll start a return-to-play progression, which is a gradual progression, where they start really with soft toss and they build up to more of a harder throw over an extended period of time, which slowly will take them back into their sport.


Dr. Mike Patrick: How long would you say that whole process takes, from the acute injury back to where you were before?


Herman Hundley: So it depends on the injury. It really does. We talked about it earlier, the longer you wait to get your arm looked at, the longer that rehab process takes.




We have kids that come in with slight strains, that come in to us early. And our calf feels a little something and we can usually rehab them pretty quick and get them back to throwing within a four-week stretch, three to four weeks. For some of those more significant Little League elbow, Little League shoulders, some of those take as long as eight weeks or even sometimes longer depending on how significant. Obviously, if needs surgery, it's much more significant period of time. But I would say anywhere between that four to eight weeks stretches is kind of common.


Dr. Mike Patrick: And a lot of these seasons don't much longer than that. And so, that can be pretty tough for kids, right? We see a lot of kids pretty emotional that they're out from their sport.


Herman Hundley: Yeah, kids struggle with that, especially those kids who are really good athletes, that are typically are going to be your pitchers and your shortstops, right? Coaches have a lot of pressure on them to win. And when their best players are out, when their good players are out, it put the strain on the team. But with the athlete being out, it's hard for them.




That's why we try to keep them involved with their team as much as possible during that time, keep them in the batting lineup and the running bases, bench running, fielding during practices. And if we can, we allow them to throw from first base which is much lighter throwing. So that they can still be involved, still help their team and then in that way, it's not excessive stress on the arm like a pitcher would have or a catcher if they're base and shortstop, something like that.


Dr. Mike Patrick: Absolutely. So let's talk about a little prevention, because if we can prevent these things from happening in the first place, then kids are not going to miss that much of their sport. And I would suspect this is really from a prevention standpoint, the responsibility of a lot of people to make sure that the things that we're going to talk about actually happen.


The kids themselves motivate them to make decisions but also parents, coaches, athletic trainers, school officials, team physicians. I mean, everybody got to come together to really make prevention of these injuries a priority.




So what are some of the things that these folks can do to help kids not get injured?


Herman Hundley: I don't like the term "injury prevention" because no injury can be a 100% prevented, but we can definitely reduce the risk of injury. There's quite a few things, but like you said, everyone is responsible. Everyone has a responsibility to help reduce those injuries. So the best way to help reduce those is going to be with proper warmup, making sure you're resting a proper amount of time. After your games and after your events, you're taking time off after pitching things like that.


So you're following the recommended pitch counts. You're following the recommended rest guidelines, and you're doing what you need to do for recovery. So getting the proper amount of sleep, making sure your nutrition is there.


Also, for a younger athletes, I think be mindful of our pitch types, not just our pitch counts. I feel like a lot of young athletes, they want to get to those breaking balls, right, the strike-out pitches. And they don't develop their fast ball and their changeup for a long enough period of time, and they don't perfect that before moving on to try and get those breaking balls.




And that's going to alter your mechanics and put excess stress on your arm which could create injuries. They say the curve ball creates elbow pain, that's not necessarily a 100% true. But going to a curve ball before you've mastered your mechanics definitely will cause some issues.


The other thing is making sure that you're strong enough, you're flexible enough and you have good conditioning levels, because fatigue does play a role. So as kids fatigue, they're going to start to alter how they're throwing the ball, which could increase stress on their shoulder and their arm.


And then obviously, like we've talked about before, proper throwing mechanics. In every injury that I've ever seen, I've never once had a kid throw with perfect mechanics. There's always something there, so it's combination of using it too much and doing it incorrectly, whether it be a little bit of both or a lot of both, sometimes.


Dr. Mike Patrick: Tom, do you have something to add?




Dr. Thomas Pommering: I was just going to add that, I think for sure, kids, also you have to remember, when they're not pitching, if they throw 60 or 70 pitches in a game, moving them to a catcher or shortstop may not be resting the elbows. So putting them into a position when they're not pitching that's not super high-throwing volume is important.


I think the other thing about pitch counts are, you have to remember that they're just a guide. And my advice to parents are that the pitch counts tell you when you should absolutely stop. But if you start having pain before the pitch count, that's really where you need to come out.


So I think, parents need to remember that, because the pitch counts don't really take into account your warm-up throws, or other throws you do outside of game situations.


Herman Hundley: To piggyback off of that, when we talk about fatigue and pitch counts, parents and coaches can really play role there. When we see a kid's mechanics start to break down, when we see them start to struggle to hit the strike zone, we start to see them alter how they're throwing.


But typically, when you see that loss of command, loss of control, they start walking kids, they start missing their spots, that's a really good sign that things are starting to break down. They're either fatiguing or they're just starting to break down their mechanics, and that's a good sign to say "That's their pitch count right there."




That's where we want to pull them in from pitching, as they build up their arm strength and build up their conditioning levels and strength and things like that. That number may go a little higher but that's kind of a good breaking point to make sure it comes out, whether that's at 60 pitches or 100 pitches, depending on their age.


Dr. Mike Patrick: When you talk about pitch counts, over what of period of time are we talking? Is it how many pitches in a game, how many pitches in a week, in a month, in a year? What kind of timeframe are we looking at with pitch counts?


Dr. Thomas Pommering: So there are different pitch counts published out there, many are pitches per game, and they'll also talk about pitches per week. And then the more pitches you may throw in a game, the more time is required to rest between pitching outings.


So again, I think you have to remember if you're not pitching but you're catching, you're still throwing the ball pretty hard back to the pitcher. You're throwing every bit as much as the pitcher is and sometimes, more, if you're throwing the balls down to the people stealing base, things like that.




Dr. Mike Patrick: So, it's really important to think about those other times that you are throwing, because those don't get counted in to those pitch counts. So like you've mentioned, if you are pitching and they take you out and put you in as a catcher, you're just still throwing. So it's something that parents can advocate for their kids, "Hey, this is still using their throwing arm, right?"


Dr. Thomas Pommering: Absolutely. I think, again, skill and control are what you should be emphasizing early on and not speed or velocity of throwing. It's the amount of throws that really damage the joints more than necessarily than the type of throws. It's your volume.


Dr. Mike Patrick: And do those pitch counts change depending on age? Or are they pretty much the same across the board?


Dr. Thomas Pommering: So again, they do lengthen based on your age. And there's an assumption there that the older you are, the more skeletally mature you are. But if you've all seen kids who are younger, some kids just mature more quickly than others, they're bigger, they're stronger, other kids are not as physically and skeletally mature.




So this is where the pitch counts aren't a one size fits all. You really just need to pay attention to heavy elbow pain, or as the things Herm mentioned, those clues that they're losing control, having issues with mechanics.


Dr. Mike Patrick: Great. Herm, you've worked with lots of pitchers of all ages through Sports Medicine. And sometimes you see kids who don't really have a lot of injury. Nothing's hurting, nothing swollen, and their mechanics changed for some reason. And they may be not as accurate as they were. They go through a stretch where they're not just pitching as well as they had been before, and then they have a good stretch.


Is there a mental aspect to pitching? We see this in the Major Leagues, where pitchers have a good stretch and then everything kind of falls apart for a while. What do you think of that?




Herman Hundley: There's definitely a mental aspect to pitching just like any other sport. But when you're in game as a pitcher, you're on an island by yourself essentially. So the balls are in your hand and it's you versus the batter. And that's what it boils down to as a pitcher. So there's going to be stretches where you get dinged up. You're going to give up home runs. You're going to get up a run.


It's really important to have some mental fortitude to be able to kind of battle through that adversity in-game. But also, there's going to be stretches where guys go through rough patches. You see this all the time with all-star pitchers in Major League, the best of the best. They're going to go three to four games, and they're going to just get smacked around.


And what it really boils down to a lot of times is just resetting and kind of taking a step back and looking at your mechanics and looking at what you're doing and what's different and going back to basics, back to your fundamentals. How did you get there?


And just kind of resetting your brain a little bit. A lot of times, they'll send those guys down to the Minor League and just give more little confidence boost, going up against some younger guys and just getting a little bit of work. They may deem it as a rehab, an outing, or whatever. But ultimately, it just gives you a chance to reset, refocus and then kind of get yourself back to your basics and your baseline.




The other mental aspect to pitching or to throwing in general is obviously having somebody awareness, being aware what proper mechanics are looking like, being coachable and being willing to change and alter your mechanics based on what your coaches are showing you or your pitching coach or whatever may come about. Just being willing to make changes and being able to make changes mentally and not just sticking with, "This is what works for me."


Because a lot of times, what's working now is not going to work long term. You're going to have an injury or something like that. So there's going to be some changes that you need to make help reduce stress but it's going to ultimately long term improve your performance.


When kids have quite a bit of anxiety about this, and it's starting to impact their quality of life and they're not really enjoying themselves anymore, do you ever get psychology involved?




Dr. Thomas Pommering: Yeah, great question, Mike. Sports should be fun. It's hard and it's challenging but it really in the end should be fun. And if we have kids who are having trouble with anxiety or stress related to their sport, then it's definitely a good time to bring in a sports psychologist or a psychologist who's comfortable talking to young athletes.


The things that athletes experience are the same kind of things that everyone experiences. They're just experiencing anxiety or stress in the setting of their sport versus in other outside settings.


Dr. Mike Patrick: Yeah, Herm.


Herman Hundley: The other thing that I would say is burnout is real for our young athletes, especially when you get them specialized very, very early. We have kids who are young as eight and ten years old, specializing in baseball year-round. They're spending all year round, they're traveling to camps, they're traveling to showcases. They go on travel teams. They are on their school team. They are seeing their pitching coach in the off season. They are seeing their hitting coach throughout the season. And they get burned out.




When you notice that the kid's not having fun anymore or they express that they're stressed or they don't seem to be enjoying their sports as much, that's a big red flag that we need to take step back and just remember that they are a kid. And then, you're not going to win a college scholarship when you're 10 or when you're 12.


Sports should be fun and if you burn them out early, they're not going to want to play when they get to high school or when they get to college. So all of that, trying to push. And that's on a lot of the parents and the coaches especially.


We got to remember that there's fundamentals and there's fun. And that's the main part that we should be remembering for our young kids.


Dr. Mike Patrick: Yeah, absolutely. Tom, tell us about the management of throwing injuries at Nationwide Children's Hospital. So if a family comes in and their kid has arm pain and they're a pitcher, it's a multidisciplinary effort, right? Tell us about the process of getting them diagnosed and treated in rehab.




Dr. Thomas Pommering: Absolutely. Definitely, you want to have a good team in place and that team will include your physician and the folks who take care of them in the clinic. And then, the second part of the treatment is the rehab team such as Herm's team. And I always say the physician's job is pretty easy. Herman's team do all the heavy lifting on these kids, by getting them pain free, making them stronger.


We talked about this earlier, when a child is an athlete’s faced with an injury that's going to take him out of sports for a while, there is coping issues. Sometimes, the families too, they're very invested, as we've talked about. So what I try to do is paint a big picture for these athletes, "By resting you and getting you healed up the right way and sending you to a really good rehab program like we have here in Nationwide Children's, we're going to make you stronger because we're going to work on these theories we haven't work on to make you a better, stronger thrower.




"We're going to make you more skilled because Herm's going to find the problem in your throwing mechanics and help you fix it. And you're going to be smarter because you're going to know how to take care of your body better. You're going to know what to look for in terms of signs of injury,"


So I think you have to have a good team in place who understands the throwers, understand their specific sport. Again, we've been talking about baseball players but we also take care of softball pitchers. And that's a different type of throwing mechanic. And again, you want to be able to take care of all types of throwers.


Dr. Mike Patrick: Absolutely. And then, you guys, of course, take care of all sorts of injuries, also concussions. We've talked with the Adaptive Sports Medicine folks in the past, sports nutrition, and you guys partner with various schools. So you're really involved in the community. Tell us a little more about just Sports Medicine in general at our hospital.


Dr. Thomas Pommering: So we definitely pride ourselves in taking care of the entire athlete. Not only athletes, but helping parents through the process of getting kids healed back. And just having a really good rehab team, sports psychology, orthopedic surgeons.


And we have eight different sites around the city. There are nine physicians in my group. They are all certified in sports medicine. And we have some special niche programs, such as, you mentioned, our Adaptive Program.




So we really want to be available for kids of all ages and abilities and not just the lead athlete, but even the weekend warrior or the kid that gets hurt in the playground.


Dr. Mike Patrick: And we'll put a link to Sports Medicine at Nationwide Children's Hospital in the show notes for this episode, 513, over at so folks can connect with you. We'll also have some other resources that you guys have put together, one on shoulder injuries in young athletes, another on elbow injuries in young athletes, and one on pitch counts and throwing injury prevention. Those are all in the form of articles and blog posts. And I'll post links to all of those things in the show notes, so folks can read a little bit more about those.


So once again, we really appreciate both of you stopping by, Dr. Tom Pommering, chief of Sports Medicine at Nationwide Children's Hospital and Herman Hundley, athletic trainer here at Nationwide Children's. Thank you both so much for being here today.




Dr. Thomas Pommering: Always great to be here. Thank you very much.


Herman Hundley: Thanks for having us, Dr. Mike. It's always a pleasure.




Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day in making PediaCast a part of it. Really do appreciate that.


Also, thanks to our guests this week, Dr. Tom Pommering and Herman Hundley, both with Sports Medicine at Nationwide Children's Hospital.


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Thanks again for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So, long, everybody.




Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.

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