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1.  Data-Based Interval Throwing Programs for Collegiate Softball Players 
Journal of Athletic Training  2002;37(2):194-203.
Objective: To construct interval throwing programs followed by a simulated game for collegiate softball players at all positions. The programs are intended to be used as functional progressions within a comprehensive rehabilitation program for an injured athlete or to augment off-season conditioning workouts.
Design and Setting: We collected data over a single season of National Collegiate Athletic Association softball at the University of Delaware and Goldey Beacom College. We observed 220 half-innings of play and 2785 pitches during data collection.
Subjects: The subjects were collegiate-level softball players at all positions of play.
Measurements: We recorded the number of pitches for pitchers. For catchers, we recorded the number of sprints to back up a play, time in the squat stance, throws back to the pitcher, and the perceived effort and distance of all other throws. We also collected the perceived effort and distance of all throws for infielders and outfielders.
Results: Pitchers threw an average of 89.61 pitches per game; catchers were in the squat stance 14.13 minutes per game; infielders threw the ball between 4.28 times per game and 6.30 times per game; and outfielders threw distances of up to 175 feet.
Conclusions: We devised the interval throwing programs from the data collected, field dimensions, the types of injuries found to occur in softball, and a general understanding of tissue healing. We designed programs that allow a safe and efficient progressive return to sport.
PMCID: PMC164345  PMID: 12937435
simulated game; college softball conditioning; rehabilitation for softball; softball injuries
2.  Incidence of Injuries in High School Softball and Baseball Players 
Journal of Athletic Training  2011;46(6):648-654.
Context:
Participation in high school sports has grown 16.1% over the last decade, but few studies have compared the overall injury risks in girls' softball and boys' baseball.
Objective:
To examine the incidence of injury in high school softball and baseball players.
Design:
Cohort study.
Setting:
Greenville, South Carolina, high schools.
Patients or Other Participants:
Softball and baseball players (n = 247) from 11 high schools.
Main Outcome Measure(s):
Injury rates, locations, types; initial or subsequent injury; practice or game setting; positions played; seasonal trends.
Results:
The overall incidence injury rate was 4.5/1000 athlete-exposures (AEs), with more injuries overall in softball players (5.6/1000 AEs) than in baseball players (4.0/1000 AEs). Baseball players had a higher initial injury rate (75.9/1000 AEs) than softball players (66.4/1000 AEs): rate ratio (RR) = 0.88, 95% confidence interval (CI) = 0.4, 1.7. The initial injury rate was higher than the subsequent injury rate for the overall sample (P < .0001) and for softball (P < .0001) and baseball (P < .001) players. For both sports, the injury rate during games (4.6/1000 AEs) was similar to that during practices (4.1/1000 AEs), RR = 1.22, 95% CI = 0.7, 2.2. Softball players were more likely to be injured in a game than were baseball players (RR = 1.92, 95% CI = 0.8, 4.3). Most injuries (77%) were mild (3.5/1000 AEs). The upper extremity accounted for the highest proportion of injuries (63.3%). The incidence of injury for pitchers was 37.3% and for position players was 15.3%. The rate of injury was highest during the first month of the season (7.96/1000 AEs).
Conclusions:
The incidence of injury was low for both softball and baseball. Most injuries were minor and affected the upper extremity. The injury rates were highest in the first month of the season, so prevention strategies should be focused on minimizing injuries and monitoring players early in the season.
PMCID: PMC3418943  PMID: 22488191
injury rates; injury epidemiology; athletic injuries
3.  Knowledge of and Compliance With Pitch Count Recommendations 
Sports Health  2012;4(3):202-204.
Background:
Pain and injuries suffered by youth pitchers are ongoing concerns that have been addressed through the institution of rules and recommendations regarding pitch counts and rest periods. The aim of our study was to see if coaches of youth baseball pitchers in our region were aware of the recommended guidelines and if they followed them.
Methods:
An Internet-based survey consisting of 18 items including demographic information and questions concerning the USA Baseball Medical and Safety Advisory Committee pitching guidelines was sent to coaches affiliated with a local youth league to assess their knowledge of and reported compliance with these recommendations.
Results:
Ninety-five of 228 coaches (41.4%) participated in the survey. On average, coaches answered 43% of questions regarding pitch count and rest periods correctly; 73% reported that they followed the recommendations, while only 53% felt that other coaches in the league abided by the recommendations. Thirty-five percent of coaches stated that their pitchers reported shoulder or elbow pain during the season, and 19% reported that one of their pitchers pitched a game with a sore or fatigued arm during the season. No coaches reported any pitching-related injuries among their players requiring surgery. Fewer than 10% of coaches reported that their players pitched in multiple leagues or participated in showcases, while 91% reported that pitchers attended camps or received specific instruction to improve their pitching form.
Conclusions:
This study shows that this subset of youth baseball coaches is deficient with regard to knowledge of the USA Baseball Medical and Safety Advisory Committee pitching guidelines. This situation may put youth pitchers at increased risk for upper extremity pain and injuries.
doi:10.1177/1941738111435632
PMCID: PMC3435927  PMID: 23016087
pediatric; baseball; pitcher; injuries; pitch count
4.  DESCRIPTIVE ANALYSIS OF PITCH VOLUME IN SOUTHEASTERN CONFERENCE BASEBALL PITCHERS 
Background:
Representative data on typical pitch volume for collegiate pitchers functioning in their specific roles is sparse and is needed for training specificity.
Objective:
To report pitch volumes in Division I collegiate pitchers. The authors hypothesize that pitcher role will result in different pitch volumes.
Methods:
Pitchers from twelve Division I collegiate baseball teams pitch volume during the 2009 baseball season was retrospectively reviewed through each team's website. The number of pitches and innings pitched for each pitcher were recorded. Pitchers were categorized based on their role as “Starter-only” (n=15), “Reliever-only” (n=76), or “Combined Starter/Reliever” (n=94) and compared using ANOVA.
Results:
“Starter-only” pitchers threw the most pitches (97±10) and pitched the most innings (6.0±1.0) per appearance (p=<.001). “Combined Starter/Reliever” functioning as a starter threw significantly more pitches (68±19) and pitched more innings (4.0±1.3) per appearance compared to “Combined Starter/Reliever” functioning as a reliever and “Reliever-only” pitchers (p=<.001). The cumulative volume during a 13 week regular season revealed that “Starter-only” pitchers threw significantly more total pitches (1204±387) compared to “Combined Starter/Reliever” pitchers (613±182) who threw significantly more than “Reliever-only” pitchers (254±77) (P<.001).
Discussion:
Pitcher's specific roles and representative volumes should be used to design training and rehabilitation programs. Comparison of this data to reported adolescent pitch volumes reveal that adolescent pitch volume per appearance approaches collegiate levels.
Conclusions:
Collegiate pitcher roles dictate their throwing volume. Starter-only pitchers (8%) throw the greatest cumulative number of pitches and should be trained differently than the majority of college pitchers (92%) who function primarily as a reliever or in combination starter/reliever roles that on average only requires approximately 40 pitches per appearance.
PMCID: PMC3097076  PMID: 21655377
Overhead Throwing Athletes; Rehabilitation; Pitching
5.  Glenohumeral Rotational Motion and Strength and Baseball Pitching Biomechanics 
Journal of Athletic Training  2012;47(3):247-256.
Context:
Addressing loss of shoulder range of motion and rotator cuff weakness in injury-prevention programs might be an effective strategy for preventing throwing arm injuries in baseball pitchers. However, the influence of these clinical measures on pitching biomechanics is unclear.
Objective:
To evaluate the relationships among clinical measures of shoulder rotational motion and strength and 3-dimensional pitching biomechanics and to evaluate the presence of coupling between the shoulder and the elbow during pitching to provide insight into the influence of clinical shoulder characteristics on elbow biomechanics.
Design:
Cross-sectional study.
Setting:
Biomechanics laboratory.
Patients or Other Participants:
A total of 27 uninjured male high school baseball pitchers (age  =  16 ± 1.1 years, height  =  183 ± 7 cm, mass  =  83 ± 12 kg).
Main Outcome Measure(s):
Clinical measures included shoulder internal- and external-rotation range of motion and peak isometric internal- and external-rotator strength. Three-dimensional upper extremity biomechanics were assessed as participants threw from an indoor pitching mound to a target at regulation distance. Linear regressions were used to assess the influence of clinical measures on the peak shoulder internal and external rotation moments and the peak elbow-adduction moment.
Results:
We found a positive relationship between clinically measured internal-rotator strength and shoulder external-rotation moment (R2  =  0.181, P  =  .04) during pitching. We also noted an inverse relationship between clinically measured external-rotation motion and the elbow-adduction moment (R2  =  0.160, P  =  .04) and shoulder internal-rotation moment (R2  =  0.250, P  =  .008) during pitching. We found a positive relationship between peak shoulder internal-rotation moment and the peak elbow-adduction moment (R2  =  0.815, P < .001) during pitching.
Conclusions:
This study provides insight into the effects of shoulder strength and motion on pitching biomechanics and how these clinical measures might contribute to throwing arm injuries in the baseball pitcher. A relationship also was identified between peak shoulder and elbow moments in the throwing arm during pitching, providing biomechanical support for addressing clinical shoulder characteristics as a potential strategy for preventing elbow injury.
PMCID: PMC3392154  PMID: 22892405
upper extremity; overhead athletes; throwing athletes; rehabilitation
6.  Prevention of Elbow Injuries in Youth Baseball Pitchers 
Sports Health  2012;4(5):419-424.
Context:
Although baseball is a relatively safe sport, numerous reports suggest a rapid rise in elbow injury rate among youth baseball pitchers.
Evidence Acquisition:
PubMed was searched for epidemiologic, biomechanical, and clinical studies of elbow injuries in baseball (keywords: “youth OR adolescent” AND baseball AND pitching AND “ulnar collateral ligament OR elbow”; published January 2000 – April 2012). Studies with relevance to youth baseball pitchers were reviewed. Relevant references from these articles were also retrieved and reviewed. Original data, insight, and recommendations were added.
Results:
The majority of baseball elbow injuries are noncontact injuries to the dominant arm resulting from repetitive pitching. Five percent of youth pitchers suffer a serious elbow or shoulder injury (requiring surgery or retirement from baseball) within 10 years. The risk factor with the strongest correlation to injury is amount of pitching. Specifically, increased pitches per game, innings pitched per season, and months pitched per year are all associated with increased risk of elbow injury. Pitching while fatigued and pitching for concurrent teams are also associated with increased risk. Pitchers who also play catcher have an increased injury risk, perhaps due to the quantity of throws playing catcher adds to the athlete’s arm. Another risk factor is poor pitching biomechanics. Improper biomechanics may increase the torque and force produced about the elbow during each pitch. Although throwing breaking pitches at a young age has been suggested as a risk factor, existing clinical, epidemiologic, and biomechanical data do not support this claim.
Conclusions:
Some elbow injuries to youth baseball pitchers can be prevented with safety rules, recommendations, education, and common sense. Scientific and medical organizations have published safety rules and recommendations, with emphasis on prevention of overuse and pitching while fatigued.
Strength-of-Recommendation Taxonomy (SORT):
A
doi:10.1177/1941738112454828
PMCID: PMC3435945  PMID: 23016115
pitcher; pitch count; ulnar collateral ligament; Tommy John surgery; curveball
7.  THORACOLUMBAR RANGE OF MOTION IN BASEBALL PITCHERS AND POSITION PLAYERS 
Introduction/Background:
Optimal baseball throwing mechanics require a significant contribution of thoracolumbar motion, particularly in the sagittal and transverse planes. This motion is key for proper transmission of forces from the lower to upper extremity, thereby minimizing a throwing athlete's risk of injury and maximizing athletic performance.
Purpose:
To define the active‐assisted thoracolumbar ROM of both baseball pitchers and position players and to compare these motions both within and between groups.
Methods:
Fifty‐six asymptomatic, collegiate and minor league baseball pitchers and 42 position players volunteered to participate. Active‐assisted thoracolumbar flexion, extension, and bilateral rotation ROM, were measured in a standing position, using two bubble inclinometers. Two‐tailed t tests were used to determine differences in ROM between and within the pitchers and position players.
Results:
The pitchers had significantly more rotation to the non‐throwing arm side as compared to the position players (p = .007, effect size = .61). The pitchers also had more rotation to the non‐throwing arm side as compared to their throwing side (p = .006, effect size = .47). There were no other significant differences between the pitchers and the position players (p > .53). Furthermore, the position players did not have a side‐to‐side rotation difference (p = .99).
Conclusions:
Pitchers have a greater amount of rotation ROM towards the non‐throwing arm side as compared to position players. Pitchers also have a greater amount of rotation ROM to the non‐throwing arm side as compared to their throwing side rotation. Because pitchers often present with posterior shoulder tightness and subsequent altered shoulder horizontal adduction and internal rotation ROM, the increase in non‐throwing side rotation ROM may occur in response to these adaptations. More specifically, this increase in non‐throwing side trunk rotation ROM may allow such athletes to bring the arm across the body during the follow‐through phase of the throwing motion despite posterior shoulder tightness. However, future research is necessary to investigate this relationship. Based on these results, clinicians should consider these thoracolumbar ROM adaptations in the prevention, evaluation, and treatment of baseball players.
Level of Evidence:
2b
PMCID: PMC3867070  PMID: 24377063
Flexibility; spine; throwing athlete; trunk
8.  Return to Sport Following Shoulder Surgery in the Elite Pitcher 
Sports Health  2013;5(4):367-376.
Context:
The ability to return to elite pitching, performance, and clinical outcomes of shoulder surgery in elite baseball pitchers are not definitively established.
Objective:
To determine (1) the rate of return to sport (RTS) in elite pitchers following shoulder surgery, (2) postoperative clinical outcomes upon RTS, and (3) performance upon RTS and to compare RTS rates in different types of shoulder surgery.
Data Sources:
Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist, Medline, SciVerse Scopus, SportDiscus, and Cochrane Central Register of Controlled Trials were searched.
Study Selection:
Levels I-IV evidence were eligible for inclusion if performance-based (eg, RTS) and/or clinical outcome–based reporting of outcomes were reported following surgical treatment of shoulder pathology in elite pitchers (major or minor league or collegiate).
Data Extraction:
Subject, shoulder, and pre- and postoperative performance-based variables of interest were extracted. All shoulder surgery types were potentially inclusive (eg, open, arthroscopic, rotator cuff, labrum, biceps, acromioclavicular joint, fracture). Study methodological quality was analyzed using the Modified Coleman Methodology Score (MCMS).
Results:
Six studies were analyzed (287 elite male pitchers [mean age, 27 years] who underwent shoulder surgery, with 99% on the dominant, throwing shoulder). MCMS was 38 (poor). Most pitchers were professional, with a mean career length of 6.58 years and postoperative clinical follow-up of 3.62 years. In 5 of 6 studies, multiple diagnoses were addressed concomitantly at surgery. Rate of RTS was 68% at mean 12 months following surgery. Twenty-two percent of Major League Baseball (MLB) pitchers never RTS in MLB. Overall performance did improve following surgery; however, this did not improve to pre-injury levels.
Conclusion:
In this systematic review, the rate of return to elite baseball pitching following surgery was established. Performance tended to decrease prior to surgery and gradually improve postoperatively, though not reaching pre-injury levels of pitching.
Level of Evidence:
IV (systematic review of studies level I-IV evidence), therapeutic.
doi:10.1177/1941738113482673
PMCID: PMC3899910  PMID: 24459557
shoulder; surgery; arthroscopy; pitcher; Major League Baseball
9.  Voluntary activation deficits of the infraspinatus present as a consequence of pitching-induced fatigue 
Hypothesis
Neuromuscular inhibition of the infraspinatus would be greater and external rotation muscle force would be lower after a simulated game compared with pregame values.
Materials and methods
The sample included 21 uninjured, asymptomatic high school–aged baseball pitchers. Maximum volitional shoulder external rotation strength was assessed before and after a simulated game with a clinical dynamometer. Voluntary activation of the infraspinatus was assessed during strength testing by a modified burst superimposition technique. Performance-related fatigue was assessed by monitoring pitch velocity, and global fatigue was assessed by subject self-report before and after the game. Statistical testing included paired and independent t tests, with α ≤ 05.
Results
There was no difference between throwing and non-throwing shoulder external rotation strength (P = .12) or voluntary infraspinatus activation (P = .27) before the game. After the game, voluntary activation was significantly lower in the throwing limb compared with pregame activation levels (P = .01). Lower external rotation strength after the game approached statistical significance (P =.06). Pitch velocity was lower in the final inning compared with first-inning velocity (P = .01), and fatigue was significantly greater after the game (P = .01).
Conclusions
Voluntary infraspinatus muscle activation is a mechanism contributing to external rotation muscle weakness in the fatigued pitcher. Understanding mechanisms contributing to muscle weakness is necessary to develop effective injury prevention and rehabilitation programs. Treatment techniques that enhance neuromuscular activation may be a useful strategy for enhancing strength in this population.
Level of evidence
Basic Science Study, Kinesiology Study.
doi:10.1016/j.jse.2011.04.012
PMCID: PMC3910170  PMID: 21831667
Baseball; rotator cuff; muscle; neuromuscular
10.  Passive Range of Motion Characteristics in the Overhead Baseball Pitcher and Their Implications for Rehabilitation 
Background
Repetitive overhead throwing motion causes motion adaptations at the glenohumeral joint that cause injury, decrease performance, and affect throwing mechanics. It is essential to define the typical range of motion (ROM) exhibited at the glenohumeral joint in the overhead thrower.
Questions/purposes
We (1) assessed the glenohumeral joint passive range of motion (PROM) characteristics in professional baseball pitchers; and (2) applied these findings clinically in a treatment program to restore normal PROM and assist in injury prevention.
Methods
From 2005 to 2010, we evaluated 369 professional baseball pitchers to assess ROM parameters, including bilateral passive shoulder external rotation (ER) at 45° of abduction, external and internal rotation (IR) at 90° abduction while in the scapular plane, and supine horizontal adduction.
Results
The mean ER was greater for the throwing and nonthrowing shoulders at 45° of abduction, 102° and 98°, respectively. The throwing shoulder ER at 90° of abduction was 132° compared with 127° on the nonthrowing shoulder. Also, the pitcher’s dominant IR PROM was 52° compared with 63° on the nondominant side. We found no statistically significant differences in total rotational motion between the sides.
Conclusions
Although we found side-to-side differences for rotational ROM and horizontal adduction, the total rotational ROM was similar.
Clinical Relevance
The clinician can use these PROM values, assessment techniques, and treatment guidelines to accurately examine and develop a treatment program for the overhead-throwing athlete.
doi:10.1007/s11999-012-2265-z
PMCID: PMC3348299  PMID: 22532313
11.  Mid-humerus adaptation in fast pitch softballers and the impact of throwing mechanics 
Purpose
Throwing is a vigorous activity that generates large internal loads. There is limited evidence of the effect of these loads on bone adaptation. The aim of this study was to investigate the: 1) magnitude of bone adaptation within the midshaft humerus of female fast-pitch softball players and 2) influence of throwing mechanics (windmill vs. overhand throwing) on the magnitude of adaptation.
Methods
Midshaft humeral bone mass, structure and estimated strength were assessed via peripheral quantitative computed tomography in fast-pitch softball players (throwers; n=15) and matched controls (controls; n=15). The effect of throwing was examined by comparing dominant-to-nondominant differences in throwers to controls, while the influence of mechanics was determined by comparing dominant-to-nondominant differences in throwers who primarily play as pitcher (windmill thrower), catcher (overhand thrower) or fielder (overhand thrower).
Results
Throwers had greater dominant-to-nondominant difference in midshaft humeral bone mass, structure and estimated strength relative to controls (all P<0.05). The largest effect was for estimated torsional strength with throwers having a mean dominant-to-nondominant difference of 22.5% (range, 6.7% to 43.9%) compared to 4.4% (range, -8.3% to 17.5%) in controls (P<0.001). Throwing mechanics appeared to influence the magnitude of skeletal adaptation, with overhand throwers having more than double dominant-to-nondominant difference in midshaft humeral bone mass, structure and estimated strength than windmill throwers (all P<0.05).
Conclusion
Throwing induces substantial skeletal adaptation at the midshaft humerus of the dominant upper extremity. Throwing mechanics appears to the influence the magnitude of adaptation as catchers and fielders (overhand throwers) had twice as much adaptation as pitchers (windmill throwers). The latter finding may have implications for skeletal injury risk at the midshaft humerus in throwing athletes.
doi:10.1249/MSS.0b013e3182134e4f
PMCID: PMC3223293  PMID: 21311354
BIOMECHANICS; BONE; EXERCISE; GROWTH AND DEVELOPMENT; MECHANICAL LOADING; OSTEOPOROSIS
12.  Comparison of Shoulder Range of Motion, Strength, and Playing Time in Uninjured High School Baseball Pitchers Who Reside in Warm- and Cold-Weather Climates 
Background
There is an assumption that baseball athletes who reside in warm-weather climates experience larger magnitude adaptations in throwing shoulder motion and strength compared with their peers who reside in cold-weather climates.
Hypotheses
(1) The warm-weather climate (WWC) group would exhibit more pronounced shoulder motion and strength adaptations than the cold-weather climate (CWC) group, and (2) the WWC group would participate in pitching activities for a greater proportion of the year than the CWC group, with the time spent pitching predicting throwing shoulder motion and strength in both groups.
Study Design
Cross-sectional study; Level of evidence, 3.
Methods
One hundred uninjured high school pitchers (50 each WWC, CWC) were recruited. Rotational shoulder motion and isometric strength were measured and participants reported the number of months per year they pitched. To identify differences between groups, t tests were performed; linear regression was used to determine the influence of pitching volume on shoulder motion and strength.
Results
The WWC group pitched more months per year than athletes from the CWC group, with the number of months spent pitching negatively related to internal rotation motion and external rotation strength. The WWC group exhibited greater shoulder range of motion in all planes compared with the CWC group, as well as significantly lower external rotation strength and external/internal rotation strength ratios. There was no difference in internal rotation strength between groups, nor a difference in the magnitude of side-to-side differences for strength or motion measures.
Conclusion
Athletes who reside in cold- and warm-weather climates exhibit differences in throwing shoulder motion and strength, related in part to the number of months spent participating in pitching activities. The amount of time spent participating in pitching activities and the magnitude of range of motion and strength adaptations in athletes who reside in warm-weather climates may make these athletes more susceptible to throwing-related injuries.
doi:10.1177/0363546510382230
PMCID: PMC3923316  PMID: 21051421
glenohumeral joint; rotational motion; rotator cuff; throwing; youth athlete
13.  A SPEED DISTANCE‐BASED CLASSIFICATION SYSTEM FOR INJURY PREVENTION AND RESEARCH IN INTERNATIONAL AND DOMESTIC YOUTH BASEBALL PLAYERS  
ABSTRACT
Background:
An objective classification system for studying youth baseball players in the U.S.A. was published in 1996. Professional baseball is composed of greater than 25% international players a majority of whom come from five countries. Many youth baseball players are injured in early years play, both in the U.S.A. and internationally. There is no international classification system to study youth baseball pitching injuries, biomechanics, or maturation, but one is needed in order to compare and combine pitchers in multi‐center studies. Uniform domestic and international pre‐injury normative data is optimum. Ideally, data collection should be practical requiring inexpensive equipment and limited time demands.
Hypothesis:
The mathematical model, developed in 1996 on 853 boys and validated on 114 boys in the Mid‐Atlantic Region, U.S.A., is internationally applicable, allowing easy classification of youth baseball pitchers and levels throughout the world.
Methods:
Seven‐hundred‐twenty‐one international pitchers, ages 8‐14, threw five full‐speed pitches recorded with a calibrated radar gun and four maximum distance throws on a marked field. Demographics included age, height, weight, and years pitched. Collection sites included foreign national baseball clubs (Dominican Republic, Venezuela, Puerto Rico, Japan and the Philippines), the Mexican national youth tournament, and a multinational tournament (Brazil, Peru and Colombia). The mathematical model developed in 1996 was used to generate predicted distances for this sample for comparison with actual distances. In addition to the overall analysis, adequate sample sizes were available for comparing predicted and actual distances by country for four of the countries.
Results:
The correlation between predicted distance using the mathematical model and actual distance was 0.90. The mean of the international players was 1‐2 standard deviations above the USA mean for speed and one standard deviation above the mean for distance. There was no systematic over or under prediction indicating that both relative and absolute fit for the model was excellent.
Conclusions:
The mathematical model developed in 1996 on U.S.A. baseball players is robustly generalizable to international youth baseball pitchers.
Clinical Relevance:
Pre‐injury distance/speed data allows for classification of youth baseball player of multiple levels between the ages of 8‐14. International and regional comparisons are now possible for multi‐center studies in order to better define risk factors, compare studies, and combine data based upon pre‐injury maximum long toss data. Data collection requires only a field, a few balls, and a tape measure.
PMCID: PMC4060312  PMID: 24944853
14.  Performance After Rotator Cuff Tear and Operative Treatment: A Case-Control Study of Major League Baseball Pitchers 
Journal of Athletic Training  2011;46(3):296-302.
Context:
Little is known about pitching performance or lack of it among Major League Baseball (MLB) pitchers who undergo operative treatment of rotator cuff tears.
Objective:
To assess pitching performance outcomes in MLB players who needed operative treatment of rotator cuff tears and to compare performance in these athletes with that in a control group of MLB players.
Design:
Case-control study.
Setting:
Publicly available player profiles, press releases, and team injury reports.
Patients or Other Participants:
Thirty-three MLB pitchers with documented surgery to treat rotator cuff tears and 117 control pitchers who did not have documented rotator cuff tears were identified.
Main Outcome Measure(s):
Major League Baseball pitching attrition and performance variables.
Results:
Players who underwent rotator cuff surgery were no more likely not to play than control players. Performance variables of players who underwent surgery improved after surgery but never returned to baseline preoperative status. Players who needed rotator cuff surgery typically were more experienced and had better earned run averages than control players.
Conclusions:
Pitchers who had symptomatic rotator cuff tears that necessitated operative treatment tended to decline gradually in performance leading up to their operations and to improve gradually over the next 3 seasons. In contrast to what we expected, they did not have a greater attrition rate than their control counterparts; however, their performances did not return to preoperative levels over the course of the study.
PMCID: PMC3419559  PMID: 21669100
pitching; clinical outcome; shoulder
15.  A Profile of Glenohumeral Internal and External Rotation Motion in the Uninjured High School Baseball Pitcher, Part I: Motion 
Journal of Athletic Training  2011;46(3):282-288.
Context:
The magnitude of motion that is normal for the throwing shoulder in uninjured baseball pitchers has not been established. Chronologic factors contributing to adaptations in motion present in the thrower's shoulder also have not been established.
Objectives:
To develop a normative profile of glenohumeral rotation motion in uninjured high school baseball pitchers and to evaluate the effect of chronologic characteristics on the development of adaptations in shoulder rotation motion.
Design:
Cohort study.
Setting:
Baseball playing field.
Patients or Other Participants:
A total of 210 uninjured male high school baseball pitchers (age = 16±1.1 years, height = 1.8 + 0.1 m, mass = 77.5±11.2 kg, pitching experience = 6±2.3 years).
Intervention(s):
Using standard goniometric techniques, we measured passive rotational glenohumeral range of motion bilaterally with participants in the supine position.
Main Outcome Measure(s):
Paired t tests were performed to identify differences in motion between limbs for the group. Analysis of variance and post hoc Tukey tests were conducted to identify differences in motion by age. Linear regressions were performed to determine the influence of chronologic factors on limb motion.
Results:
Rotation motion characteristics for the population were established. We found no difference between sides for external rotation (ER) at 0° of abduction (t209 = 0.658, P = .51), but we found side-to-side differences in ER (t209 = −13.012, P<.001) and internal rotation (t209 = 15.304, P<.001) at 90° of abduction. Age at the time of testing was a significant negative predictor of ER motion for the dominant shoulder (R2 = 0.019, P = .049) because less ER motion occurred at the dominant shoulder with advancing age. We found no differences in rotation motion in the dominant shoulder across ages (F4,205 range, 0.451–1.730, P>.05).
Conclusions:
This range-of-motion profile might be used to assist with the interpretation of normal and atypical shoulder rotation motion in this population. Chronologic characteristics of athletes had no influence on range-of-motion adaptations in the thrower's shoulder.
PMCID: PMC3419557  PMID: 21669098
shoulder; throwing; range of motion
16.  A controlled study on batted ball speed and available pitcher reaction time in slowpitch softball 
Objectives: To investigate safety risks in slowpitch softball by conducting laboratory and experimental studies on the performance of high tech softball bats with polyurethane softballs. To compare the results with the recommended safety standards.
Methods: ASTM standard compression testing of seven softball models was conducted. Using these seven softball models, bat/ball impact testing was performed using seven adult male softball players and six high tech softball bat models to determine mean batted ball speeds. Over 500 bat/ball impact measurements were recorded and analysed. Available pitcher reaction time was calculated from the mean batted ball speed measurements.
Results: According to the United States Specialty Sports Association and the Amateur Softball Association, the maximum initial batted ball speed should be 137.2 km/h, which corresponds to a minimum pitcher reaction time of 0.420 second. These experiments produced mean batted ball speeds of 134.0–159.7 km/h, which correspond to available pitcher reaction times of 0.409–0.361 second.
Conclusion: The use of high tech softball bats with polyurethane softballs can result in batted ball speeds that exceed the recommended safety limits, which correspond to decreased available pitcher reaction times.
doi:10.1136/bjsm.2004.012724
PMCID: PMC1725191  PMID: 15793092
17.  The epidemiology of single season musculoskeletal injuries in professional baseball 
Orthopedic Reviews  2013;5(1):e3.
The aim of this descriptive epidemiology study was to evaluate the injury incidence, pattern and type as a function of position in one professional baseball organization for one complete season. The study was carried out in a major academic center. Participants were all major/minor league baseball players playing for one professional organization. The disabled/injury list of one single professional baseball organization (major and minor league players) was reviewed for all of the injuries and the number of total days missed secondary to each injury. All injuries were categorized into major anatomic zones that included: shoulder, elbow, wrist/hand, back, abdomen/groin, hip, knee, and ankle/foot. The data was further stratified based on the injury type and the number of days missed due to that particular injury and a statistical analysis was performed. In pitchers, elbow injuries (n=12) resulted in 466 days missed. In catchers, wrist injuries (n=4) resulted in 89 days missed. In position players, abdominal/groin injuries (n=16) resulted in 318 days missed and shoulder injuries (n=9) resulted in 527 days missed. Overall, 134 players were injured and a total of 3209 days were missed. Pitchers had 27 times and 34 times the rate of days missed due to elbow injuries compared to position players and all players, respectively. Abdominal and groin injuries caused the pitchers to have 5.6 times and 6.4 times the rate of days missed than the position and all players, respectively. Both elbow and abdominal/groin injuries are the most disabling injury pattern seen in pitchers. Among the position players, shoulder injuries resulted in the most days missed and knee injuries resulted in the highest rate of days missed in both pitchers and catchers.
doi:10.4081/or.2013.e3
PMCID: PMC3662259  PMID: 23705061
MLB baseball; epidemiology; upper body injuries; lower body injuries; abdominal/ groin injuries.
18.  A Profile of Glenohumeral Internal and External Rotation Motion in the Uninjured High School Baseball Pitcher, Part II: Strength 
Journal of Athletic Training  2011;46(3):289-295.
Context:
A database describing the range of normal rotator cuff strength values in uninjured high school pitchers has not been established. Chronologic factors that contribute to adaptations in strength also have not been established.
Objectives:
To establish a normative profile of rotator cuff strength in uninjured high school baseball pitchers and to determine whether bilateral differences in rotator cuff strength are normal findings in this age group.
Design:
Cohort study.
Setting:
Baseball playing field.
Patients or Other Participants:
A total of 165 uninjured male high school baseball pitchers (age = 16 ± 1 years, height = 1.8 ± 0.1 m, mass = 76.8 ± 10.1 kg, pitching experience = 7 ± 2 years).
Main Outcome Measure(s):
Isometric rotator cuff strength was measured bilaterally with a handheld dynamometer. We calculated side-to-side differences in strength (external rotation [ER], internal rotation [IR], and the ratio of ER:IR at 90° of abduction), differences in strength by age, and the influence of chronologic factors (participant age, years of pitching experience) on limb strength.
Results:
Side-to-side differences in strength were found for ER, IR, and ER:IR ratio at 90° of abduction. Age at the time of testing was a significant but weak predictor of both ER strength (R2 = 0.032, P = .02) and the ER:IR ratio (R2 = 0.051, P = .004) at 90° of abduction.
Conclusions:
We established a normative profile of rotator cuff strength for the uninjured high school baseball pitcher that might be used to assist clinicians and researchers in the interpretation of muscle strength performance in this population. These data further suggested that dominant-limb adaptations in rotator cuff strength are a normal finding in this age group and did not demonstrate that these adaptations were a consequence of the age at the time of testing or the number of years of pitching experience.
PMCID: PMC3419558  PMID: 21669099
shoulder; muscle physiology; throwing
19.  Glenoid Stress Distribution in Baseball Players Using Computed Tomography Osteoabsorptiometry: A Pilot Study 
Background
It is important to understand the loading conditions when considering the pathology of shoulder disorders in overhead athletes. However, because throwing is a complicated motion and methods to directly determine stress distribution are complex, direct measurement of the stress distribution across the glenohumeral joint has not been attempted. Subchondral bone density reportedly reflects the cumulative stress acting on a joint surface under actual loading conditions.
Questions/purposes
To assess alterations in stress distribution across the glenoid cavity caused by pitching, we investigated the distribution of subchondral bone density in nonathletic volunteers and asymptomatic baseball players, including fielders and pitchers.
Methods
We collected CT imaging data from the dominant-side shoulder of 10 nonathletic volunteers (controls), 10 fielders, and 10 pitchers in a competitive college baseball league (all men aged 19–24 years, mean 20.7 years). We measured the distribution of subchondral bone density of the glenoid cavity using CT osteoabsorptiometry. The obtained stress distribution map was divided into four segments: anterosuperior, anteroinferior, posteroinferior, and posterosuperior regions. We quantitatively analyzed the location and percentages of high-density regions on the articular surface.
Results
The percentages of high-density regions, including the anteroinferior and posterior segments, were greater in pitchers and fielders than in controls. The percentages of high-density regions did not differ between pitchers and fielders.
Conclusions
The bicentric density patterns indicated that the cumulative force of pitching activity affected the long-term stress distribution across the glenoid cavity.
Clinical Relevance
Our data should be useful for analyzing pitching activity and clarifying the pathology of shoulder disorders associated with throwing.
doi:10.1007/s11999-012-2256-0
PMCID: PMC3348294  PMID: 22290131
20.  Review of the Windmill Pitch: Biomechanics and Injuries 
Abstract
Objective
To review the literature of the biomechanics of the windmill fast-pitch and its implications for injury. This information may be utilized in treating youth windmill pitchers.
Data Source
A MEDLINE search was conducted to retrieve articles regarding the windmill pitch. Key terms were then taken from the pilot search and used to conduct a systematic search and review of the literature.
Results
Articles containing information on the windmill pitch and injuries associated with the motion were reviewed. Additional information pertaining to the overhand baseball pitch and overuse injuries in youth were analyzed and synthesized into the body of information.
Conclusion
A complex sequence of actions is required to successfully perform the windmill pitch. Overuse injuries are common in windmill pitchers. A well-designed conditioning schedule and the regulation of the frequency and volume of pitching in youth fast-pitch may assist with managing injury associated with this activity. Further investigation of specific treatment methods is needed.
doi:10.1016/S0899-3467(07)60086-X
PMCID: PMC2646989  PMID: 19674624
Biomechanics; Underhand Pitching; Softball; Chiropractic; Shoulder; Elbow
21.  Glenohumeral Rotational Range of Motion in Collegiate Overhead-Throwing Athletes During an Athletic Season 
Journal of Athletic Training  2009;44(6):611-616.
Abstract
Context:
Repetitive throwing at high velocities leads to altered range of motion (ROM) in the dominant shoulder compared with the nondominant shoulder in overhead-throwing athletes. Loss of glenohumeral internal rotation (IR), or glenohumeral internal-rotation deficit (GIRD), is associated with shoulder injuries. Therefore, GIRD should be evaluated during the clinical examination of the thrower's shoulder.
Objective:
To assess glenohumeral ROM in competitive baseball and softball athletes at 3 intervals over the course of an athletic season in order to (1) examine changes in ROM over time and (2) monitor the prevalence of GIRD.
Design:
Observational, repeated-measures study.
Setting:
Collegiate athletic training room.
Patients or Other Participants:
Forty-eight healthy National Collegiate Athletic Association (NCAA) Division I or Division II athletes (age  =  19 ± 1 years, height  =  174 ± 14 cm, mass  =  77.8 ± 18.1 kg; 19 softball, 29 baseball players).
Main Outcome Measure(s):
We measured glenohumeral IR, external rotation (ER), total arc (ER + IR), and GIRD at 3 times: prefall, prespring, and postspring. We calculated GIRD in 2 ways: as the difference in IR between dominant and nondominant shoulders and as the percentage of the total arc.
Results:
In the dominant shoulder, ER increased during the season (F2,96  =  17.433, P < .001), but IR remained the same (F2,96  =  1.839, P  =  .17). The total arc in the dominant shoulder increased between time intervals (F2,96  =  14.030, P < .001); the mean difference between prefall and postspring measurements was 9.694° (P < .001), and the mean difference between prefall and postspring measurements was 10.990° (P < .001). In the nondominant shoulder, ER increased over the season (F2,96  =  23.395, P < .001), but IR did not change over the season (F2,96  =  0.087, P  =  .90). The total arc in the nondominant shoulder increased between prefall and prespring measurements and between prefall and postspring measurements (F2,96  =  18.552, P < .001). No changes were noted in GIRD over time. However, more athletes with GIRD were identified with the GIRD (IR difference) calculation in prefall (n  =  6) than in prespring (n  =  1) and postspring (n  =  4) (Cochran Q  =  5.2, P  =  .07). In addition, more athletes with GIRD were identified with the GIRD (% total arc) calculation in postspring (n  =  6) than in prefall (n  =  5) or prespring (n  =  4) (Cochran Q  =  2.6, P  =  .27).
Conclusions:
Healthy NCAA Division I and Division II athletes did not display changes in glenohumeral IR over an athletic season. However, they gained in ER and total arc during the season in both shoulders. Future researchers should investigate changes over multiple seasons. The 2 methods of calculating GIRD identified different athletes as having GIRD, indicating that additional investigation is warranted to determine the clinical benefits of each method.
doi:10.4085/1062-6050-44.6.611
PMCID: PMC2775362  PMID: 19911087
shoulder; upper extremity; glenohumeral internal-rotation deficit
22.  THROWING INJURIES IN THE ADOLESCENT ATHLETE 
Introduction:
Adolescents ranging in age from 11–15 (early‐mid adolescence) comprise the largest percentage of baseball and softball athletes in the United States. Shoulder and elbow injuries are commonly experienced by these athletes with baseball pitchers and softball position players most likely to be injured.
Common Injuries:
Physeal injury often termed “Little League” shoulder or elbow is common and should be differentiated from soft tissue injuries such as biceps, rotator cuff, or UCL injuries. Regardless of diagnosis, rehabilitation of these athletes’ shoulder and elbow injuries provide a unique challenge given their rapidly changing physical status.
Treatment:
Common impairments include alterations in shoulder range of motion, decreased muscle performance, and poor neuromuscular control of the scapula, core, and lower extremity. A criterion based, progressive rehabilitation program is presented. Discharge from formal rehabilitation should occur only when the athlete has demonstrated a resolution of symptoms, acceptable ROM, muscle performance, and neuromuscular control while progressing through a symptom free return to sport.
Prevention of Reinjury:
Reintegration into the desired level of sport participation should be guided by the sports medicine professional with a focus on long‐term durability in sport performance as well as injury prevention. A prevention program which includes parent, coach, and athlete education, regular screening to identify those athletes at the highest risk, and monitoring athletes for the development of risk factors or warning signs of injury over the course of participation is indicated.
Level of Evidence:
5
PMCID: PMC3811729  PMID: 24175142
Adolescent; throwing injuries; youth
23.  Baseball Pitching Biomechanics in Relation to Injury Risk and Performance 
Sports Health  2009;1(4):314-320.
Context:
Baseball pitching kinematics, kinetics, ball velocity, and injuries at the shoulder and elbow are related.
Evidence Acquisition:
PubMed and Sport Discus were searched for original studies published between 1994 and 2008. Relevant references in these studies were retrieved. Inferential studies that tested relationships between kinematics and kinetics were included, as were studies that tested relationships between kinematics and ball velocity. Descriptive studies that simply quantified kinematics and/or kinetics were excluded.
Results:
Several kinematic parameters at the instant of foot contact were associated with increased upper extremity kinetics: front foot position, front foot orientation, shoulder abduction, and shoulder horizontal adduction. The timing of shoulder external rotation, pelvis rotation, and upper trunk rotation was associated with increased kinetics and decreased ball velocity. Low braking force of the lead leg and a short stride were associated with decreased ball velocity. Decreased maximum shoulder external rotation, shoulder abduction, knee extension, and trunk tilt were also associated with decreased ball velocity. As pitchers develop, kinematic values remain similar, their variability reduces, and kinetic values gradually increase. Slight kinematic variations were seen among pitch types, although the kinetics of fastballs and curveballs were relatively the same; changeup kinetics were the lowest. As pitchers fatigued, kinetic values remained constant, but increases in arm pain were reported.
Conclusions:
Several kinematic parameters were related to joint kinetics and ball velocity. To enhance performance and reduce injury risk, pitchers need to learn proper fastball mechanics at an early age. A changeup is recommended as a safe secondary pitch to complement the fastball; the curveball can be added after fastball and changeup mechanics are mastered. Avoiding overuse and pitching while fatigued is necessary to minimize the risk of arm injury.
doi:10.1177/1941738109338546
PMCID: PMC3445126  PMID: 23015888
shoulder; elbow; ball velocity; kinetics; mechanics
24.  Magnetic Resonance Imaging of the Throwing Elbow in the Uninjured, High School–Aged Baseball Pitcher 
Background
Tissue adaptations in response to pitching are an expected finding during magnetic resonance imaging (MRI) evaluation of the throwing elbow of adult pitchers. These changes are considered normal in the absence of symptom complaints. It is unclear when during the playing career these tissue adaptations are initiated.
Hypothesis
Abnormalities in the appearance of the throwing elbow compared with the nonthrowing elbow would be visible during MRI assessment of this asymptomatic population of high school–aged throwers.
Study Design
Cross-sectional study; Level of evidence, 3.
Methods
Twenty-three uninjured, asymptomatic male high school–aged baseball pitchers (mean age, 16 years) with no history of elbow injury were recruited for the study. Participants had a minimum of 3 years’ experience with pitching as their primary position (mean experience, 6 years). Bilateral elbow MRI examinations were performed using a standardized protocol including fast spin-echo proton-density (axial and coronal), T1-weighted (sagittal), and T2-weighted fat-saturated (axial, sagittal, and coronal) sequences. Osteoarticular, ligamentous, musculotendinous, and neural structures were evaluated and compared bilaterally. The images were reviewed by a musculoskeletal radiologist who was blinded to all the gathered data on these athletes, including limb dominance.
Results
Three participants (13%) had no abnormalities. Fifteen individuals (65%) had asymmetrical anterior band ulnar collateral ligament thickening, including 4 individuals who also had mild sublime tubercle/anteromedial facet edema. Fourteen participants (61%) had posteromedial subchondral sclerosis of the ulnotrochlear articulation, including 8 (35%) with a posteromedial ulnotrochlear osteophyte, and 4 (17%) with mild posteromedial ulnotrochlear chondromalacia. Ten individuals (43%) had multiple abnormal findings in the throwing elbow.
Conclusion
Thickening of the anterior band of the ulnar collateral ligament and posteromedial subchondral sclerosis of the trochlea are common findings in the high school–aged pitcher and may be considered normal clinical findings in the absence of symptom complaints. Other changes in tissue appearance of the throwing elbow are uncommon in this age group and should be regarded with a higher level of caution when evaluating for the presence of injury. An understanding of the MRI appearance of the uninjured youth pitcher is necessary for clinicians to distinguish between normal adaptations and the presence of injury.
doi:10.1177/0363546510390185
PMCID: PMC3947520  PMID: 21228309
overhead athlete; MRI; ulnar collateral ligament
25.  Impulse Noise: Can Hitting a Softball Harm Your Hearing? 
The Scientific World Journal  2014;2014:702723.
The purpose of this study is to identify whether or not different materials of softball bats (wooden, aluminum, and composite) are a potential risk harm to hearing when batting players strike a 12′′ core .40 softball during slow, underhand pitch typical of recreational games. Peak sound pressure level measurements and spectral analyses were conducted for three controlled softball pitches to a batting participant using each of the different bat materials in an unused outdoor playing field with regulation distances between the pitcher's mound and batter's box. The results revealed that highest recorded peak sound pressure level was recorded from the aluminum (124.6 dBC) bat followed by the composite (121.2 dBC) and wooden (120.0 dBC) bats. Spectral analysis revealed composite and wooden bats with similar broadly distributed amplitude-frequency response. The aluminum bat also produced a broadly distributed amplitude-frequency response, but there were also two very distinct peaks at around 1700 Hz and 2260 Hz above the noise floor that produced its ringing (or ping) sound after being struck. Impulse (transient) sounds less than 140 dBC may permit multiple exposures, and softball bats used in a recreational slow pitch may pose little to no risk to hearing.
doi:10.1155/2014/702723
PMCID: PMC3981188  PMID: 24778596

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