Collateral Damage: The Elbow Injury Epidemic in Baseball

Now that the 2017 Major League Baseball regular season has drawn to a close, fans of the sport will have to find some way to pass the time until the next season starts in April. Many will spend the winter months looking over stats. For these self-described “nerds,” baseball offers a goldmine of data. A full baseball season consists of 2,430 games with thousands of at-bats serving as data points that can provide clear insight into how players performed that year. Home runs, stolen bases, strikeouts, OPS, WAR and dozens of other metrics are not just used by fans at a bar arguing over who should win the Most Valuable Player award, but also by the front offices of teams deciding who is deserving of a big-money contract before the next season.

For these team executives, a much simpler statistic can indicate how a player’s season went: ulnar collateral ligament tears. If a player’s number under this column doesn’t say “0” at the end of the season, then they likely had a rough year and may be in for a rough season the following year as well. This is because elbow UCL tears are devastating. By the nature of baseball, it is not an injury you can simply play through. A torn UCL absolutely requires surgery and rehab that can take around a full year before a player can play on a baseball diamond again.

The UCL connects the humerus to the ulna and is crucial for stabilizing the elbow during both flexion and extension. For the average joe, incurring an injury to the UCL is exceedingly unlikely. If you play baseball, whether you are little-leaguer or an MLB superstar, the threat of a tear is very real. The throwing motion almost universally adopted to throw a baseball exerts extreme stress on the elbow. This motion has been reported to subject the UCL to 60 Newton meters, a force that the UCLs tested in cadavers cannot support. As baseball has become more competitive over the last century, players have been throwing harder and harder and the forces endured by their UCLs have become concomitantly greater and greater. It is for this reason that baseball players and pitchers in particular, often suffer UCL tears, an issue that is practically endemic to the sport.

In the past, these injuries were less common simply because the average MLB pitcher did not throw as hard as he does today. This century alone, the speed of the average MLB pitcher’s fastball has increased from 88 to 91 mph. For those that did have the misfortune of sustaining the injury, their careers were jeopardized. When Tommy John of the Los Angeles Dodgers tore his UCL in 1974, he resorted to an experimental reconstructive surgery performed by team doctor Frank Jobe. The procedure was an overwhelming success and is still widely performed on baseball players to this day bearing the name “Tommy John Surgery” (TJS). Recipients of TJS who commit to their rehabilitation generally have a very high likelihood of playing baseball again at the same level prior to the rupture. Still, dozens of MLB players and hundreds of amateur athletes undergo the year-long recovery process every year. Professionals who are injured fortunately have access to skilled physicians and the financial resources needed for the long recovery, but sadly the same is not necessarily true for afflicted children. While the problem may be less widespread and insidious as something like concussions in football, it is still a sad reality that exists.

This sort of problem is nothing new to the game of baseball. As the sport exerts so much strain on the arm, injuries in the past largely centered around the shoulder. During the second half of the 20th century, rotator cuff injuries would consistently end baseball careers. Not much was understood about the nature of the injuries or how to treat them, so players who blew out their shoulders and required reconstructive surgeries were often out of luck. Strangely, sports doctors today don’t hear much about those sorts of injuries in baseball anymore. Whereas those injuries had been about as prevalent as UCL injuries are today, the problem has been significantly ameliorated. Clearly something must have changed in baseball to account for this change in affliction. Have pitchers simply shifted the demands of throwing from their shoulders to their elbows? Common sense would tell you “no” and, if anything, the freak athletes who throw over 100 mph today must surely place more stress on their shoulders than their predecessors. So what changed?

What happened is the baseball community reacted to the crisis and worked towards a culture change. Never before has such a large emphasis been placed on shoulder muscle strengthening and longevity training. Stretching programs have become the norm for preparing all parts of the body for performance of any kind, but in baseball a great amount of focus is particularly applied to shoulders. Gone are the days of the laissez-faire approach to pitching that was common in the past. During those times, if a pitcher felt ready to pitch and was selected by their managers to do so, then they would do so and nobody would bat an eye. Fast-forward to today and you see pitching rotations by which starting pitchers in the MLB only play every fifth game. Furthermore, managers have more delicate control over rookies and can decide at the beginning of the season that they will only allow those players to pitch a specific number of innings that year. Reform can be seen in youth leagues as well; there are now regulations on throwing curveballs before a certain age (as this pitch requires a particularly violent follow-through), pitch count limits during games and tournaments, closer pitcher’s mounds and more. Baseball coaches and players saw the problem that existed and successfully worked towards a future in which shoulder injuries would be less prevalent.

Certainly, the same can and must be done with elbow injuries. Just because a reliable treatment exists for UCL tears doesn’t mean we should accept so many athletes, especially children, needing to endure a year of intense recovery. The dilemma of course, is that you can never tell someone to throw slower and expect them to oblige. The idea that “if I don’t throw hard, someone else will” is very true in such a competitive sport played by so many people. Perhaps there is more we can do to educate coaches and players about ways to care for the elbow such that catastrophic injuries can be kept to a minimum. Major organizations including the MLB and Little League Baseball have pushed the “Pitch Smart” initiative. This program has been adopted by youth leagues and involves educating coaches on how to train their players to throw with less strain on the elbow. Also included are the implementation of pitch counts based on age, as well as mandatory rest days following a game in which a certain amount of pitches were thrown. The hope is that this will bring about an extension of the culture change created by addressing shoulder injuries. By having kids throw less and with a more streamlined motion, childhood elbow injuries will ideally be curtailed and those who make it to the major leagues will have the tools and endurance to pitch a full, healthy career.