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04/14/08 10:00 PM ET

Avoiding injuries starts in Little League

Throwing too many pitches or wrong kind dangerous to kids

You can trace the history of baseball injuries back to The Stone Age. The first recorded injury probably took place in a Pee-wee championship game between the Bedrock Giants and the Grittsburg Pyrites.

It happened to involve the umpire -- one Fred Flintstone -- who was knocked out in a collision at home plate, and upon coming to, called the Pyrite runner safe, giving Grittsburg the title. There was no joy in Bedrock that day, let me tell you. (Mr. Slate's son, Eugene, was called out on strikes five times. Amazingly, Fred kept his job at the quarry!)

I don't recall whether Bam Bam was pitching that day, but I do know that pitch count wasn't an issue. It wasn't until fairly recently that Little League Baseball instituted rules limiting the number of pitches that players could throw in competition and mandated specific rest periods based on the number of pitches delivered. It was done for the same reason that Major League clubs keep pitch counts low -- to protect the health of the players.

"There is absolutely a correlation between the number of pitches thrown and an increased risk of injury," says Dr. Arun Ramappa, chief of sports medicine at Beth Israel Deaconess Medical Center in Boston. "Take a look at the players on the disabled list. The majority of them are pitchers with shoulder or elbow problems. It's the same at every level of the game right down to Little League."

Young women aren't immune, either. Among girls who participate in softball, it's also pitchers who have a higher incidence of shoulder and elbow injury.

One survey of nearly 500 young pitchers 9-14 years old showed that the occurrence of pain the day after a game increased in direct proportion to the number of pitches thrown. When tracked over the entire season, the results were dramatic. Using 200 pitches as a baseline, the study showed that youngsters who threw 400-600 pitches doubled the reports of pain. Those that threw more than 600 pitches were three times as likely to describe shoulder or elbow pain.

The fact is while professional ball players put far more strain on their arms than younger athletes, Little Leaguers and adolescents are more susceptible to certain injuries. That is because in a younger, growing body, the growth plates in both the elbow and shoulder joints have not closed.

Elbow injuries are most common among young pitchers. "Little League Elbow" is a medically recognized condition that results from the stresses on the joint structure caused by repetitive throwing. Characterized by tenderness and swelling to the inner elbow, the more severe cases can involve stress fractures and cartilage damage.

"We know for a fact that too much throwing is going to affect the growth plate," said Dr. Ramappa. "It's been demonstrated that in kids with a history of significant pitching, the position of the top of their arm relative to the shaft of the humerus, changes. What's not as clear is whether this is the body's attempt to 'protect' the arm. Regardless, it's a sign of the effects of pitching on a growing body."

Whether or not the change is a form of self-protection, it is known that proper mechanics play a role in the prevention of injury. A young body is ill-equipped to deal with the extraordinary strain that certain pitches put on the arm.

"Kids have got to stay away from curveballs and sliders. It's just not a good idea to attempt to throw breaking balls before the growth plates are closed," stresses Dr. Ramappa. "Exactly when that occurs varies from player to player, of course. It's tied more to puberty than age, so a better indication may be when a boy begins to shave."

By the way, it's not just medical experts who advocate waiting when it comes to breaking balls. A few years ago, Dr. Joseph Chandler, director of medical services emeritus for the Atlanta Braves, asked over 100 pitchers in the Braves organization when it was that they first started to throw a curveball. The average age was 14. He then asked the pitchers when they would allow their own sons to start. The average age was 15. And that's from the horse's mouths.

Being a horse -- a player who can shoulder a heavy workload -- has generally been accepted as a compliment in baseball. But good old fashioned horse sense will tell you that moderation is key.

Better pitchers are more likely to participate on more than one team and are generally asked by their coaches to pitch more innings. Couple that with the fact that as their velocity increases so does the stress on their joints, and that means they also have a higher risk of injury.

"I know from talking with colleagues that there's been a dramatic increase in the number of surgical interventions on young pitchers. Every year more young athletes undergo ulnar collateral ligament surgery or Tommy John surgery as it's more widely known," noted Dr. Ramappa. (UCL surgery involves replacing the ligament with a tendon taken from elsewhere in the body, usually the forearm). "It's a procedure that can take only an hour to perform, but the rehabilitation lasts about 11 months. Even then, there's no guarantee that a player will return to preinjury form."

"Preventing an injury is always preferable to repairing one. Parents and coaches really have to educate themselves," he said. "Most of our kids are never going to pitch in the Major Leagues. Let's try to help them get through Little League in good shape."

Gary Gillis is a contributor to MLB.com. The BID Injury Report is a regular column on redsox.com. Beth Israel Deaconess Medical Center is the official hospital of The Boston Red Sox. This story was not subject to the approval of Major League Baseball or its clubs.