Phillips throwing out first pitch at Redbirds game

Listen up if you have little leaguers, aspiring basketball or soccer stars in your midst. With kids playing sports at such an early age, there are things you need to know to keep them in the game.

Barry Phillips, MD, orthopedic surgeon and team physician for the Memphis Redbirds, the University of Memphis, Rhodes College,  AAA Baseball and the Memphis Riverkings, talked recently about some of the most common sports injuries encountered by school athletes as well as college athletes and professional players.

Baseball and pitch counts

“The sports medical societies have made a big push to get coaches and trainers to recognize (the importance of) keeping pitch counts for young pitchers all the way up through the major and minor leagues. When you hit a certain number, they take you out,” said Phillips. Elbows and shoulders are the most frequently injured joints in baseball and pitchers are watched for early signs of problems.

Research on mechanics supports recommendations to prevent injuries. According to Phillips, six or seven year olds should keep their pitch count in the 60s; mid-teens in the 70s and 80s and late teens (high school level) between 80 and 90. At 90 pitches you are out. “Fatigue is a big part of pitching, so if you can keep the pitch count down, it keeps the mechanics better, they don’t get fatigued and it helps prevent injuries,” said Phillips.

“Some of the young kids warm up for an hour before the game. They are already fatigued,” Phillips warned. Excessive warming up makes a pitcher more prone to injury. “There’s no magic number but the younger you are, the less you can throw, some more than others,” said Phillips.

Stress and vulnerabilities

“The growth plate is a big issue. Young teenagers have more overuse injuries to the growth plate. The ‘little league elbow’ (also known as osteochondritis dessicans or OCD) is medial epicondyle apophysitis and comes from throwing too much and interfering with the normal growth plate of the elbow.” Comprised of cartilage cells, the growth plate is more vulnerable to injury than bone. Too much pitching causes stress on the growth plate and medial epicondyle where the forearm muscles attach, causing inflammation and pain.

“Players can develop the same type injury to the shoulder – ‘little league shoulder’ or proximal humeral epiphysitis. They throw too much, it causes stress and it doesn’t grow as it should. The player develops pain and can get progressive loss of function.” This injury is also seen in volleyball players and racket sports.

Loss of function is the death knell for the athlete, whether school age or professional. But just because a pitcher has pain as a teenager, doesn’t necessarily mean that he or she will be unable to play in high school, Phillips advised. What is important, said Phillips, is that it’s paid attention to and that the player doesn’t just pitch through it.

“You have to watch for growth plate injuries in the younger kids and ligamentous injury or rotator cuff problems in the older kids. Once the growth plates settle down and heal back, rarely do they have a problem unless they keep on pitching and pull the growth plate loose,” said Phillips. “Most rotator cuff problems in pitchers are a partial undersurface tear to the cuff and can usually be repaired or cleaned out (debrided) and do pretty well.”

Moderation is key

Pitching coaches video their players’ pitching mechanics and watch for any kind of change. Too many pitches and bad mechanics cause injuries. Good mechanics allow you to pitch more and stay within a reasonable pitch count, decrease fatigue and help prevent injuries, added Phillips.

Like pitchers, catchers also suffer shoulder injuries. “Catchers throw from awkward positions down the bases with gear on and their arm at a poor angle. They get shoulder injuries too, but more commonly it’s the pitchers who have a rotator cuff or SLAP tear (superior labrum from anterior to posterior) – which is a superior labral tear.”

The labrum is a cuff of cartilage that forms a cup for the humerus; the area where the labral tear occurs is susceptible to injury because of its poor vascularity. “Pitchers commonly suffer SLAP tears from repetitive throwing. They develop pain and the inability to throw at the level they’re accustomed to,” Phillips pointed out. This is one of the more common injuries he sees that often requires surgical repair.

“Treatment is conservative to try to prevent the pitcher from having a contracture of the shoulder, or the glenoid internal rotation defect (GIRD). When they lose internal rotation, they can’t rotate their arm all the way in and that’s a common way to develop a labral tear. You have altered the mechanics of the shoulder because of the contracture,” explained Phillips.

Prevention

Prevention has been the focus for the past 10 years to prevent contractures using ultrasound and stretching. “Chris Conroy is the trainer for Redbirds and he works with the Cardinals,” said Phillips. “Every spring they develop different stretch techniques to make sure that pitchers keep all the range of motion of their shoulder, strengthening the rotator cuff and preventing internal rotation of the joint.”   

Advances in technique and comebacks

According to Phillips, orthopedics has made quantum leaps since he was a resident. The arthroscopic rotator cuff repairs and the arthroscopy Bankart repairs for shoulder instability (repair to the capsule) are much more advanced.

“When I started, there were no anchor sutures (like a toggle bolt with sutures through it), which is what we use to sew the labrum back down to the bone. Now we have anchors that make smaller holes in the bone, provide a more secure fixation, heal in better and are stronger.” Arthroscopic tacks are made of absorbable polyglycolic acid. “And the suture anchors, formerly made of metal, now have a mixture of hydroxyapatite – a bone supplement that actually incorporates into the bone.”

A year to 18 months can seem like a lifetime for an athlete recovering from surgery but that’s how long it can take to get back to throwing well for a pitcher after a reconstruction surgery. “An ulnar collateral ligament (UCL) injury is the one that requires the ‘Tommy John’ procedure where you take a tendon and reconstruct the ligament,” said Phillips. (John was a pitcher for the LA Dodgers and was first to undergo the procedure in the 70s.)

On the cutting edge?

A hot topic in orthopedics is platelet-rich plasma therapy (PRP) – a procedure used to spin down a sample of the patient’s own blood to separate and concentrate the platelets which are then injected into the joint. The growth factors the platelets secrete are thought to speed tissue healing. Its effectiveness is unproven but some claim it works.

Tiger Woods and Pittsburgh Steelers Hines Ward and Troy Polamalu have all received PRP therapy for knee injuries. “When you’re a professional athlete and getting treatment 22 hours a day, you are going to get better faster than someone who gets an hour of therapy a day,” Phillips cautioned. Not a strong proponent of PRP, Phillips said, “With platelet-rich plasma, you…get the growth factors which do stimulate healing but how long they stay around and how much long term effect you get is controversial.”

Prevention campaigns and programs

The STOP (Sports Trauma and Overuse Prevention) program is a public outreach campaign designed to raise awareness, encourage safety and prevent sports injury initiated by the American Orthopaedic Society for Sports Medicine and is supported by all the sports medicine groups.

“When I first started working with women’s athletics in 1987, the injury rate was tremendously higher. One of the programs that has been developed is the JUMP program – players stop, cut, jump and learn to land on both feet to decrease knee injuries.” Interestingly, the majority of sports injuries of the knee are in female sports, according to Phillips. “As far as participants per hour of play, women have the higher rate of injury in gymnastics, soccer and basketball, even than football, though it is better now than it was,” said Phillips.

Conditioning, conditioning…

The advice Phillips imparts is to show up in good condition, stay in good condition and, if there is pain in a shoulder or elbow that doesn’t go away, have it checked out. It’s best not to play through pain, but if you do, be sure you are not doing further damage to the joint, he said.

Phillips was captivated with sports medicine during his residency when he worked with orthopedic giants Marcus Stewart, MD and David Sisk, MD. “I started going to University of Memphis games and talking to them – I liked what they did and their skills. It looked like a good way to go.”

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