The second half of our two-part “Armcare” series features a Q&A with two of the foremost experts on shoulder and elbow injuries.
Why do you think we haven’t seen a pronounced spike like this in injury rates before?
Michael Ciccotti: Part of it might be that we didn’t understand these injuries quite as much at the time as we do now. Ballplayers today, with the way they’re recruited into high school, college and ultimately professional baseball, it almost necessitates that they start focusing on exclusively baseball at incredibly early ages. Arguably, they have more mileage on them than the elite level ballplayers decades ago, and more mileage on them than multi-sport athletes today.
Up until college and sometimes through college, players used to play multiple sports; there was a broad balance of stress throughout the musculoskeletal system, rather than years and years of competitive stress in the same areas of the body. It’s like having two beautiful cars; one of them has a thousand miles on it and the other has 50,000 miles on it. They look the same, they’re both beautiful, but the car that has 50,000 miles on it is more likely to have problems than the other car.
What can coaches do to mitigate the occurrence of arm injuries with their players?
Ben Kibler: Coaches are very observational and analytical. They can pick out a lot of things and compare them to the standard that they’ve developed. We need to look for the cause of the observed motions: the elbow dips because the shoulder is tired, the shoulder blade is slumping down or the legs are weak. Arms are slow because of hip weakness, resulting in the arm being behind. If you look at the legs, you can find most of the problems associated with the hand, you can find hip weakness or a tight back. It is possible to observe these things, so coaches and doctors need to work together to agree on what is happening.
I worked with the Houston Astros for several years, and we got the point where the coaches and I were talking the same language, talking about the same things. Now I’m working to make that happen with the Kansas City Royals. The point is that sitting down across the table from each other is the best way to do it- ‘this is what I see, what do you see?’
Ultimately, it’s our goal to provide information through research to the coaches, allowing them go get the best players possible on their teams programs. The players benefit because things are getting done right and the professional teams are benefitting because in general, they’re getting a higher-quality product with less miles on it. It’s a big win all the way around if we can do this right.
MC: One of the things that coaches can provide has to do with mechanics of throwing. Some coaches are brilliant with that and other coaches are novice, but I think the majority of coaches have a sense of [the mechanics of throwing] and how to optimize mechanics. Number two is encouraging athletes to be well-conditioned from the ground-up. We’re focused on the shoulder and the elbow, but coaches can help make sure these athletes are involved in some sort of conditioning program that involves the legs, hips, and core along with the upper extremities.
When you’re a collegiate coach, it’s really hard; you’re there to win and your job security is often dependent on winning with 18, 19, and 20-year olds. You want the best players and you want them to be available.
How would you explain these injury rates in Latin American countries?
MC: A lot of Major League Baseball teams are infiltrating Latin America and Central America and presenting the principles that we are teaching. The reality is that for so many of those players, baseball is their ticket; baseball is their way to move on to a better life. They want to play as much as they can and be as good as they can so they have a chance to provide a better life for themselves and their families. A lot of times, what we’re trying to teach about rest, taking time off and balanced exercise can fall on deaf ears.
I do think it’s better because of the way that Major League Baseball has infiltrated those areas, with scouts, camps, and winter ball leagues. The overuse part of it is hard to maneuver around, but there’s another sport [in Latin America] that’s amazingly popular and arguably more popular than baseball, and that’s soccer. Some of these baseball athletes are soccer players too, which gives them an alternate sport and a chance to avoid the intense specialization that [youth athletes in the United States] are now participating in.
How would you go about explaining the ‘ideal’ pitching mechanics to a novice coach?
BK: In addition with the work I do in baseball, I work with professional tennis players and we’re facing the same issue defining what the best mechanics are- that’s really my main area of focus with research. We know that there are more efficient ways of making the baseball- or the tennis ball- go where you want it to go with maximum velocity and the least amount of strain on your body. There’s no doubt that there are ways of doing that, there’s just a lot of variability with those parameters, a lot of ways to stand on the mound and deliver the ball. There have been a couple of very good biomechanical studies in the lab, and the job is translating these findings to the field.
There are certain mechanics that we know are not good: a dropped elbow, the ‘reverse W,’ drifting towards first or third base with your front leg. These are all observable things that we know from experience do not produce good results with performance and health. If your elbow drops, you’re going to be high and arm side with location. If you can’t get on top of the ball, you won’t get much bite on your slider, for example. If you’re drifting, you can end up with a slow arm. These things do exist, so the question is: what’s the best way of looking at this?
How can these principles be applied specifically to college baseball?
BK: With college baseball, I’d probably decrease the emphasis on fall ball. I see nothing wrong with some, but it should be like the pros- fall instructional league, not as competitive. You see what happens every time they have the World Baseball Classic, there are always two or three big time pitchers that blow out. They’re pitching too much too soon. In college, you go February to June and go play summer ball in the warmer months. When college players come back to school, I’d make sure that they arrive on campus intact. They’re all going to have weakness in the shoulder and tightness in the hip; they need some time to recover. This is ‘instructional league,’ this is when your long relief guys need to become starters, when you need a new closing pitcher. So in short, fewer games, more instruction, less throws, monitoring physical capabilities like shoulder rotation, hip weakness, etc. very carefully, and giving them that time off. That’s when you hit the weights seriously and develop most all of your core strength.
What is the foremost factor that can help ‘fix’ these issues?
MC: This is something that takes a lot of focus. It takes people from a broad spectrum of baseball- not just physicians, but trainers, epidemiologists, coaches and strength and conditioning coordinators- to come together and ‘cross-pollinate’ in terms of thoughts in order to figure this out. It’s not just sports specialization, it’s not just overuse, it’s not just poor mechanics, it’s all of these factors. We haven’t figured out the relative percentages, and we can debate which is most important or least important. Major League Baseball is focused on getting these people together and has initiated this process, and we’re in the midst of developing a broad study that will not just involve professional baseball players, but ideally collegiate, high school and youth players as well.
Michael G. Ciccotti, MD
The Everett J. and Marian Gordon Professor of Orthopaedic Surgery
Sidney Kimmel Medical College at Thomas Jefferson University
Chief, Division of Sports Medicine
Director, Sports Medicine Fellowship and Research
The Rothman Institute at Thomas Jefferson University
Head Team Physician, Philadelphia Phillies
Dr. W. Ben Kibler has been with the Lexington Legends since their inaugural season in 2001.
Board-certified orthopedic surgeon specializing in sports medicine and shoulder and elbow conditions with the Lexington Clinic
Has been involved in spring training medical education for all levels of the Houston Astros’ sports medicine staff
Lectures nationally and internationally on shoulder injuries and has been active in research efforts to improve treatment of shoulder and sports injuries
Fellow in the American College of Sports Medicine
Member of the American Shoulder & Elbow Society and the American Orthopedic Society for Sports Medicine
Dr. Kibler received his M.D. from Vanderbilt University, where he was an All-SEC outfielder for the Commodore baseball team