Limiting Risk of Injury for Overhead Throwing Athletes

overhead throwing pitcher baseballAs summer is upon us, I thought it might be helpful to review some advice and practical tips for our overhead throwing athletes.

It’s an excellent idea to follow age-specific guidelines and limits on both innings pitched and number of pitches thrown. These help to minimize fatigue and overuse injuries.

Additionally, throwing when the player experiences shoulder or elbow pain leads to a dramatically increased risk of injury. The presence of shoulder or elbow pain in an overhead throwing athlete is not something to push through. Your sports medicine physician, athletic trainer, or physical therapist needs to know about this.

Keep in mind that it is perfectly OK, and probably very healthy, to take some time off during the year from overhead throwing. Cross training or participating in other sports will have some significant upside for making you a better athlete as well as keeping you healthy.

You can’t help your team if you’re hurt and not on the field. Follow the above simple steps to maximize your arm health and stay in the game!
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Free Educational Seminar on Tommy John Injuries

Please Join Dr. Marshall Kuremsky and Alan Tomczykowski, DPT for a Free Educational Seminar on Tommy John Injuries in Baseball: Prevention, Patterns, Research, & Treatment.

February 2, 2019
Registration at 8:45AM
Space is limited, please RSVP by January 30, 2019 to or
by phone at 919-281-1958.

Key Learning Objectives – Attendees will be able to:

  1. Describe the historical perspective of Tommy John injuries.
  2. Identify anatomy of the elbow, specifically associate with injury.
  3. Identify trends, research and data on both youth and professional baseball players at risk for a Tommy John injury.
  4. Describe both non-surgical and surgical treatment options.
  5. Perform screening and assessment, as well as functional correctives for throwers.
  6. Apply Functional Performance Pyramid and progression to skill work (throwing mechanics) vs foundational training and therapy.
EmergeOrtho is recognized by the Board of Certification, Inc. to offer continuing education for Certified Athletic Trainers. This program has been approved for a maximum of 2.5 hours of Category A continuing education.
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Shoulder Pain Is Common Complaint In Baseball Players

baseball-pitcherShoulder pain is a very common complaint in baseball players, for both pitchers and position players all too regularly. Fortunately, the vast majority of these can be treated without surgery, and just require proper evaluation by a sports medicine physician who can then organize the treatment plan to get the athlete healthy again.

The most common source of shoulder pain in the baseball players that I see is impingement, which leads to the clinical condition known as bursitis. You may hear these terms used interchangeably, as they are trying to describe the same set of symptoms, but they do mean different things. Typically this is pain with the arm maximally elevated, or even any throwing position of maximal external rotation and abduction. This is also known as the “late cocking phase” for pitchers.

Most overhead throwing athletes have slightly more shoulder external rotation – with correspondingly less shoulder internal rotation – on their throwing arm compared to their non-dominant arm. It’s always interesting to show this to the athlete or family members in the office. Fortunately, proper focus on stretching of the posterior capsule to allow more shoulder internal rotation is a very helpful therapeutic step. When shoulder pain is quite bad, I frequently will use anti-inflammatory medications or a Cortisone injection to the shoulder as well. This can be very helpful not only to reduce the amount of pain, but also to shut down the inflammation. We typically recommend some time away from throwing to allow pain to subside as well.

Of course, there are other diagnoses – there can be biceps tendinitis, a small labral tear, a specific type of torn labrum known as a slap lesion, or even a partial small rotator cuff tear. These are less common and still surgery is not frequently necessary. I am very liberal about obtaining an MRI with contrast dye for shoulder as well as asking about other injuries in my baseball players.

If you are a baseball player having an ongoing shoulder issue, I recommend you see an Orthopedic surgeon who is a sports medicine specialist, preferably one with experience in treating baseball players.

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Pitch Counts Can Prevent Elbow Injuries

baseball-pitcherOne of the most important ways in which to keep our young athletes healthy, when they’re involved in baseball for most or all of the year, is by pitch counts. Perhaps it would be more appropriate to call them pitch limits. Fortunately, through research we have been able to establish some reasonable guidelines to help keep young throwing arms as healthy as possible. The best website I have found is

This is a simple but thorough set of guidelines based upon age. As our young players get older and more mature, their shoulders and elbows are better adapted to throw more pitches, harder, and more frequently. Young athletes feel strong tensile forces at growth plates which can cause pain from overuse or chronic repetitive stresses. There’s a reason that the term Little Leaguer’s shoulder and Little Leaguer’s elbow exist!

Whether we are sports medicine physicians, concerned parents, or knowledgeable athletes, we are all looking to stay on the field. We don’t help our team much, or continue to develop athletically, if we are hurt and unable to participate. Guidelines for pitch counts or pitch limits assume that athletes are playing the majority of the year. Baseball has become quite competitive, with lots of showcases, camps, and travel ball – all in addition to high school and junior high teams.

Remember some other simple and effective advice from some of my earlier blogs. Namely, try to avoid the phenomenon of double dipping – pitching one day, and then being the primary catcher for the team on the other days – as it’s simply too much stress on the elbow with all of the throws back to the mound. Remember to cross train as well, becoming a better athlete by participating in other sports – which also gives the shoulder and elbow a break. And remember to take at least two months off from throwing per year.

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PRP – What Is It and Can It Fix Me?

PRP treating knee and elbow injuriesBy now a majority of people have heard of PRP, which stands for platelet-rich plasma. This is a procedure performed by a physician in the office that involves taking a small sample of blood from a patient. That blood is then placed into a centrifuge machine, which helps to separate the blood into different layers based upon their densities. A specific density layer is targeted which contains the platelets and growth factors responsible for the healing process invoked when we have injured tissues. This layer is then typically injected into patients at the target site of injury, often under ultrasound to enhance the precision of the injection.

The popularity for this treatment really took off when several professional athletes turned to injections of PRP for different reasons in order to help them. Famously, Hines Ward of the Pittsburgh Steelers had his MCL injury to his knee injected when he sustained a grade 2 sprain just two weeks before the super bowl. Kobe Bryant and Dirk Nowitzki in the NBA have had their knees injected as well during their careers.

There is an important and growing role for the use of PRP in baseball players, most commonly in the elbow for partial tears of the ulnar collateral ligament, or UCL (Tommy John ligament). Certainly, we do not think that a complete or full thickness tear can be treated with this injection; that will require surgical intervention if the pitcher wishes to return to play. However, in the properly selected patient and with proper technique, there is a role for PRP injections for some partial tears. This is usually based on a thorough patient history, physical examination, and review of recent X-rays and an MRI with contrast injected into the joint (aka ‘arthrogram’). After PRP injection, there is a period of time away from throwing, followed buy a return to throwing program.

We are still actively conducting high quality research studies to elucidate the volume and frequency of injections, as well as comparing these injections to other injection types or even placebos to ensure that we can understand the science and statistics behind when and if this treatment is superior.

Ask your sports medicine physician with expertise in treating baseball injuries if PRP is an option for you or your child.

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Growth Plate Fractures in Children

My child has a growth plate fracture in their arm – should I be really worried? I see patients of all ages, from toddlers to the elderly. A large part of my practice involves treatment of routine injuries in children, adolescents, and teenagers. Fractures of the hand, wrist, forearm and elbow are very common. Here’s a little bit about how we grow: The growth plates are the centers of growth and the location of lots of injuries. We get longer in our bones because of the growth plates. The growth plate is also the weak spot on the bone. It is largely made up of cartilage which eventually ossifies or turns into bone – like the remainder of the more mature bone. The cartilage isn’t as strong as regular bone.

On an x-ray, you can tell if somebody is still growing based on the presence or absence of growth plates at specific, known locations within the bone. If the growth plate is still very wide-meaning lots of distance from the rest of the bone on either side of the growth plate-then the child is younger. As a child ages, the growth plate narrows, until eventually it is just a thin line between two parts of that bone, and eventually it becomes invisible all together. At this point, the bone is done growing.

We classify fractures involving the growth plates using something called The Salter-Harris classification. There are five subtypes of classifications, increasing in severity of injury and problems to the bone with increasing number. Fortunately, most growth plate fractures are a type 1 or type 2 Salter-Harris fracture – which is the most mild kind. While it is possible to have disruption or problems related to future growth with any type of growth plate fracture, fortunately they are pretty uncommon for type one and two fractures. Also, most kids sustain a type one or type two fracture as well – not the more serious types (3-5).

So – in short, if you or your child sustained a fracture to the growth plate, do not necessarily worry! Get it checked by somebody who is comfortable treating orthopedic injuries in kids of all ages. Most of the time, this is the more mild type involving a type one or two fracture. Most of these do not have any long-term sequela to the injury. Also, bones can tolerate being a little bit angulated, or crooked, particularly in very young kids. Their bodies know to grow the bones straighter overtime. The younger the patient, the more crooked the bone could be; there are certain specific parameters that we measure based on age and the x-ray. The growth plate is weaker than the ligaments, tendons, or remainder of the shaft of the bone, so this is where most injuries occur. Chances are, your child will heal up just fine and be back at it in no time!

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Prevent Baseball Arm Injuries With Proper Rest and Cross Training

baseball arm injuriesHow can I rest my throwing arm when there is never any off-season?

In high school and college we have our respective school teams. After those Spring seasons…there is travel ball. Then Fall ball. And Showcases. Of course, there’s AAU and other tournaments.

I am often asked by parents what their kids can do to avoid injuring their throwing elbows and shoulders.

The foundation and principles for remaining in the game and taking care of your arm have been well-established. They include – but are not limited to – adhering to pitch counts, proper mechanics, not throwing when fatigued or tired, and ensuring proper rest between outings especially for starting pitchers.

But the risk of having a significant shoulder or elbow injury – the most significant of which would be injury to the elbow ulnar collateral ligament (UCL) necessitating UCL or Tommy John surgery – is very real.

These days, there is tremendous opportunity – but also real pressure – to be involved in baseball around the clock. Weight training is not only done by all players now, but it is done at an increasingly earlier age. Teams and opportunities to play or showcase are essentially year around. Some parents have told me that if their child is not playing in baseball or softball all 12 months out of the year that they will “fall behind their peers” – it’s just what they believe.

It’s important that we remember to cross train. No one sport can provide any and all of the work and exercise required to be the best athlete possible. We all need to mix in and incorporate other activities and forms of exercise to improve our overall athletic skill set – that includes our strength, flexibility, agility, hand-eye coordination, the psychological and mental aspects pertinent to our sports, and the list goes on and on.

If you love an overhead throwing sport such as baseball or softball, try to get involved in some other activities. Running, swimming, yoga and basketball are just a few sports and activities that can help round out your athletic performance.

This issue comes up every summer when high school and collegiate teams have ended their respective seasons and the summer is here. Summer teams, showcases, tournaments, and camps are just some of the many examples available where baseball players continue to do baseball related activities. In fact, there really is no offseason whatsoever for these young and developing arms – the players keep going, just the formats are different. This is one of the most notable ways that injuries can occur because there has been no time off or rest, to avoid overuse injuries that could lead to surgery such as Tommy John UCL reconstruction.

Take some time to let your arm rest and develop – it will pay big dividends for you in the future. See a sports medicine professional should you wish to discuss more about this.

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Dr. Kuremsky and Sports Medicine

sports medicine UCL injuriesMost of us have heard of the phrase – “The art of medicine”. That refers to the unique interaction between a physician and their patient, taking into account all of the particular and individual nuances that make up one patient’s problem(s). The same treatment will not work universally for every patient. A physician draws upon their experiences and their fund of knowledge to customize the care provided to each individual patient. That, in essence, is the art of medicine.

I am fortunate enough to have expertise in something similar – “The Art of Sports Medicine.” I credit this experience largely to my full year of subspecialty advanced fellowship training in orthopedic sports medicine – A year that was spent at the American Sports Medicine Institute in Birmingham Alabama. Dr. James Andrews, and his partners, have created the eminent sports medicine mecca in this country where athletes of professional, collegiate, and high school ranks frequently travel to to seek their expertise.

The skills gained and the experience earned during this year were invaluable. We took care of MVP running backs in the NFL, World Series winning pitchers in major league baseball, national championship winning football players from both Alabama and Auburn. And yet, nobody got the same identical treatment. Everybody got the same technical expertise and effort during surgery, but the conversations, relationships, and individualized care and attention were unique to each patient athlete.

In my orthopedic practice, I have extracted the same principles. Every patient of mine gets an individualized treatment plan and thought assessment from me personally. In particular, my athletes – regardless of level and including our weekend warriors – will get a customized and thorough evaluation as well as treatment recommendations from me.

One of my passions is care of the upper extremity in the athlete – from the shoulder down to the fingers. I have the privilege of treating many baseball players and serve as the team physician for the Houston Astros single-A affiliate, the Holly Springs Salamanders, as well as Campbell University and the University of Mount Olive. Care of the athlete’s shoulder and elbow is a very special situation, particularly as it relates to baseball or softball.

There is a growing epidemic regarding injuries to the ulnar collateral ligament (UCL) of the elbow – a problem which is frequently treated with what is commonly known as Tommy John surgery. Other treatment options exist, such as platelet rich plasma (PRP) injections, periods of rest without throwing, and a dedicated return to throwing program.

Each athlete gets a treatment plan tailored to their needs. I take into account many variables – the patient’s age, current level of competition, future ambitions within the sport, and also the time of year during which they are hurt. Different treatment options exist for the baseball player hurt in February versus August, in my opinion.

Together, we can come up with the right treatment plan for you or your family member for their upper extremity and sports medicine needs.
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Elbow Injuries and Tommy John UCL Surgery

baseball player throwing athlete elbow injuryOne of the most interesting yet challenging aspects of taking care of baseball players are discussions regarding injuries to the ulnar collateral ligament. This condition, which is extremely common, causes medial or inner elbow pain in overhead athletes. It can be seen in baseball or softball players, volleyball players, football players, or track and field athletes. It is certainly extremely common in the sport of baseball.

This condition is diagnosed with a proper history and physical exam, as well as input from x-rays and an MRI.

As is often the case, there are a spectrum of injuries and a lot of terminology that is thrown around. Sometimes this can be confusing for the patient and their families. It is my job to help to sort it out. Words like sprain, tear, complete versus incomplete, partial, etc. can often be used. This can create confusion and anxiety, but a good sports medicine physician can help you sort things out.

For baseball players with a complete detachment of the ligament from their elbow, Tommy John surgery is unequivocally recommended. This has an excellent track record and a very favorable return to pre-injury activity levels. For patients with pain, loss of velocity, or inability to compete at the proper level with a complete or full thickness tear of the ligament, this treatment approach works well and typically should be followed.

Decisions exist and uncertainty arises when there are partial or incomplete tears of the ligaments. Some people will be candidates for nonsurgical options – most commonly, this refers to treatment with an injection of the patient’s own blood, called platelet rich plasma, or PRP. PRP uses a centrifuge machine to spin down a sample of blood from the patient, to inject a specific layer of the blood that is rich in growth factors, platelets and cytokines-elements which helps stimulate a healing response. In some instances, we believe that the PRP can help the athlete’s native tissue to heal on its own without surgery. This is not always the case, however.

Not everybody is a candidate for PRP. There are certain things which come into play that need to be discussed with your physician. Briefly, this includes the time of the year during which the athlete is being seen, the prior history of injuries or lack thereof about the elbow, and the specific characteristics of the ligament that we can see on the MRI, among other things. Some candidates have true potential to heal the ligaments with PRP and time. Others, unfortunately, will be unable to heal a ligament that is highly disorganized, stretched out, or badly injured, even if it is not completely torn off the bone.

When working on this problem together with you or your family member, we can come up with the best approach that makes sense, taking all of these variables into consideration. Indeed, it is a complex subject, but I and my team can help you sort it out.

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Ulnar Collateral Ligament Injuries and Treatment

The phrase “Tommy John” refers to injury sustained to the athlete’s elbow, specifically the ulnar collateral ligament or UCL. Surgical treatment of this injury is known as Tommy John reconstructive surgery, whereby a new ligament is recreated to replace the function of the injured one.

Tommy John himself was a successful baseball player in the 1970s and 80s for the Los Angeles Dodgers and the New York Yankees. His fame truly derives from the fact that his career appeared to be in jeopardy when he sustained an injury to his inner elbow at the UCL. At that time, no professional major-league baseball pitcher had ever returned to play after having sustained this significant injury.

Behind the treatment and pioneering work of Dr Frank Jobe, John had surgery and ultimately returned to continue playing baseball – and had several more exceptional years. From here, other players also began to have this surgery and henceforth the procedure known as “Tommy John” refers to elbow ligament reconstruction in athletes.

The incidence of Tommy John injuries is rising. Of even greater concern is the fact that injuries are happening not only more frequently but to younger athletes. It is estimated that more than 55% of all pictures in the major and minor leagues have had Tommy John surgery.

Research has provided insight into the mechanism of injury. These include some of the following: year-round throwing, failure to adhere to established pitch counts and pitch limits, initiating curveballs at an early age or before mastery of fastballs and breaking balls, poor throwing mechanics, and others.

Throwing athletes of all ages should see a sports medicine elbow specialist if they are having elbow pain or a decrease in velocity when throwing. An experienced physician can help sort out the diagnosis as well as provide next steps for treatments or rehabilitation.
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