From the WebMD Archives

April 12, 2019 -- It’s a sunny spring afternoon in the Atlanta suburbs. The ring of the bat, the smack of a ball in a glove, and the cheers of the parents mean baseball is back.

It’s the bottom of the first inning, and coach Tracy Bracken’s Braves -- a batch of 9-year-old Little Leaguers -- are on the field. At the end of the dugout, assistant coach Dane Lorio is logging each throw from the team’s young pitcher, tapping a button on an iPhone app called Pitch X.

Lorio says the players know he’s counting pitches, but all of them may not grasp why it’s being done.

Baseball is perhaps the most statistic-intensive major sport. Fans in the cheap seats and front-office executives in the major leagues alike obsess over batting averages, earned-run averages, and on-base percentages.

But the numbers Lorio keeps may be as important to a Little Leaguer’s future as strikeouts or velocity. The pitch count is now subject to strict rules that are meant to keep growing arms from needing major surgery down the road.

The number of young players having “Tommy John” surgery, which replaces or repairs the tissue that ties together the bones of the elbow, began to skyrocket 2 decades ago. Sports medicine experts have called it an epidemic driven by the expansion of youth sports leagues, the rise in the number of kids focusing on just one sport and playing it year-round, competitive pressure, and myths about the procedure.

While the increase in surgeries appears to have slowed nationally in the past decade, they have not yet gone down, says Steve Jordan, MD, an orthopedic surgeon at the Andrews Institute for Orthopaedics and Sports Medicine in Florida.

“In baseball overall, we’ve seen elbow injuries still go up, even though the shoulder and other problems started to turn around 2010 to 2015,” says Jordan, who tracks insurance data on the procedure.

The problem led the man for whom the now-famous surgery is named to criticize the youth-sports industry for putting kids at risk.

“The nation’s youth-sports industry is a $15 billion business -- and more and more, that business pushes children to make decisions early about which sport they want to play, and then to pursue that sport to the exclusion of all others,” John wrote in a 2018 column for AARP The Magazine. “And kids’ bodies are paying the price.”

A Big Jump in Tommy John Surgeries

Reconstruction of the ulnar collateral ligament, or UCL, got its nickname from John, the Los Angeles Dodgers pitcher who first had the procedure in 1974. During the surgery, doctors replace a torn ligament with a section of tendon taken from another part of the body, such as the leg or wrist. In John’s case, the procedure not only repaired what would have been a career-ending injury, but John went on to pitch in the majors until age 46.

More than 500 pro players have had Tommy John surgery since then. But James Andrews, MD, the founder of the Florida clinic, and some of his colleagues started raising alarms in the mid-1990s after noticing a sharp rise in the number of young players who’d had the procedure.

The number of teens getting UCLs rebuilt grew from fewer than a dozen a year in the early 1990s to more than 40 by 2010. By 2011, more than half of Tommy John surgeries were done on kids ages 15 to 19. At the college level, a study of nearly 5,300 players in the 2017 season found 134 needed UCL surgery.

The drive to succeed has led to a kind of mythology around Tommy John surgery, with some young players and coaches considering it almost routine.

“There are literally Tommy John surgeries that aren’t really needed,” says Guerry Baldwin, president of East Cobb Baseball in suburban Atlanta. Some minor-league players who have other elbow problems go ahead and have the procedure, believing they’ll throw harder afterward.

But a 2014 study from The American Journal of Sports Medicine found that average ball velocity of a major league pitcher actually falls slightly -- less than 1 MPH -- in the years after Tommy John surgery.

In a 2012 survey of coaches, parents, and high school or college ballplayers, Columbia University researchers found roughly a third of parents and coaches, half of college players, and a quarter of high-school players thought athletes should get the surgery, whether or not they had an elbow injury, “to enhance performance.” They also tend to underestimate the recovery time, which is typically a year to 18 months -- and 1 in 5 major league pitchers never get back to their pre-surgery performance afterward, the American Sports Medicine Institute says.

Putting Limits on Pitches

Pitch counts for young players took root at the urging of sports medicine specialists like Andrews, one of the leading figures in sports medicine. The more pitches thrown in a game, the more time a kid has to take off before throwing again. The practice has been mandatory throughout the national Little League organization since 2006, and since 2017 in high schools.

But not everyone appears to be following the rules precisely. A 2014 survey of youth baseball players found 43% of pitchers threw on consecutive days and 90% had pitched more than one game a day in the past year.

While every sport has its risks, baseball pitchers are particularly vulnerable to elbow and shoulder problems, Jordan says.

Throwing a baseball overhand at high speed “is not a natural act,” says Bracken, the Little League coach. “That’s why softball pitchers can throw underhand 5 days in a row, but a baseball pitcher needs four or 5 days’ rest after throwing.”

Bracken speaks from experience. He was a college pitcher and a pro prospect who played briefly in the Detroit Tigers’ farm system. In addition to giving kids their first tastes of the game, he’s coached aspiring college and pro players.

At the end of the 9-year-olds’ game, Bracken feeds his pitchers’ numbers into a spreadsheet that automatically calculates how long a player has to stay off the mound. He’s also a league commissioner, so he has to collect other managers’ numbers.

“We stick to this very strictly,” he says. “Coaches are reminded not to start kids too fast, ice their arms, make sure they have plenty of rest in between, and they’re not just going from pitching to catching or another high-use position.”

The pitch count system that the Little League follows varies depending on a player’s age. For the 9-year-olds Bracken coaches, a kid who throws between 21 and 35 pitches needs at least 1 day off before taking the mound again. Up to 50 pitches means 2 days’ rest.

Up to 65, and it’s 3 days. More than 65? Four days. And nobody throws more than 75 pitches in a game. The numbers go up as kids get older, but even the oldest players are limited to 95 pitches.

There are things besides overuse that can contribute to an arm injury. Poor mechanics -- for instance, using only the arm rather than the entire body to deliver force behind the pitch -- can put more strain on the elbow. Throwing fastballs all the time doesn’t help.

Even a child’s height can play a part, Jordan says, since the leverage provided by longer arms puts more force on the elbow.

“What we’re telling parents and coaches now is to pay particular attention to that tall hard-thrower, boy or girl, and don’t throw them every time you can,” says Jordan, the Andrews Institute doctor. “Little Leaguers want to throw that big, hard-throwing person as much as they can, and we’re trying to tell them that’s risky.”

But the No. 1 problem is throwing when tired. Growing bodies need rest. Jordan says players who pitch while fatigued are 35 times more likely to get a pitching injury later.

The American Sports Medicine Institute recommends young players take at least 2 months off from throwing a ball at all. Bracken thinks it should be 3 to 4.

“At this point in their lives, they’re growing so fast that if you keep their arms and shoulders under constant pressure and stress, they never strengthen naturally the way they should,” he says. And an off-season where the child isn’t throwing a ball “would also assist greatly in alleviating this injury problem that we’re seeing so much of right now.”

Meanwhile, as the number of youth sports organizations and leagues have grown, the youth baseball season has grown longer. It’s not unusual for some kids to play baseball year-round. Many recreational leagues offer fall, spring, and summer seasons with just weeks in between. There are also school teams and various amateur baseball leagues that play in summers and into the fall. In the 2014 study of youth baseball players, 30% of pitchers played for multiple teams with overlapping seasons.

And young players who are serious about the game can join travel leagues like East Cobb Baseball, about 20 miles up the road from where Bracken’s kids play. The organization fields dozens of teams from ages 8 to 18. It has an impressive track record of players who’ve gone on to win baseball scholarships or reach the pros, including dozens of current and former major leaguers. Its office walls are packed with trophies.

East Cobb president Guerry Baldwin is skeptical about pitch counts, arguing that innings pitched is a better way to tell how much rest time a player needs.

“I get why they did it. It was done to protect kids from overzealous coaches and/or dads that become too fired up about winning a tournament on a weekend,” he says. Pitch counts are “part of the culture” of youth sports now, but he adds, “I don’t see how you can pick a pitch limit and determine that’s enough for a kid to throw.”

Baldwin says leagues like his have become a scapegoat for the rising number of injuries, “and we’re not.” He says East Cobb takes better care of its players than some other programs, including high schools.

Pitchers regularly get 4 or 5 days off between outings, he says. Baldwin warns players away from trendy workout routines, like throwing with weighted balls, and he won’t allow radar guns, which he and others say encourage pitchers to try to light them up with fastballs rather than focusing on other pitches that might put less strain on their arms.

“I guess they have to have somebody to blame, so they’re blaming summer baseball, or travel baseball,” he says. Ultimately, Baldwin says, the responsibility to protect a young arm starts with the players and their families.

“Who’s at fault is the kid and his father for allowing it,” he says.

Baldwin says some East Cobb players -- “not that many” -- have gotten Tommy John surgery. The most recent was Braxton Garrett, who played three seasons at East Cobb, went on to throw for a championship-winning U.S. national amateur team, and was drafted in the first round by the Miami Marlins in 2016 for more than $4 million, only to need the surgery in his first season in the minor leagues. He’s now back to pitching in the minor leagues for the Marlins.

“I don’t know when his elbow started hurting,” Baldwin says. “He never, ever said a word to me about his elbow being sore in the 3 years he played for me. But he did, and he had it, and he’s back. He’s fine now, and the ligament they put in was way bigger, so he’ll be stronger and better than ever.”

‘Always a Case-by-Case Basis’

Some of those who get the surgery may do it with an eye on making it to the majors later on. But veteran baseball scouts say that while Tommy John isn’t disqualifying for a young prospect, it’s something teams have to weigh carefully.

While it’s not as big a concern as it used to be, “it’s always a case-by-case basis,” says Jim Beattie, a retired Toronto Blue Jays scout. Team doctors will review a player’s medical records and notes from the doctor who did the surgery and discuss how the recovery process is going, he says.

Dave Littlefield, vice president of player development for the Detroit Tigers, says scouts “definitely” look differently at a player who’s had Tommy John surgery.

“For a pitcher in particular, it’s a pretty significant injury, and there is data that a bunch of them don’t come back to a level you once saw them at,” he says. While some players who have had the surgery go on to do well in the major leagues, “There’s obviously a lot of gray in there.”

“It’s not necessarily a deal killer, but you also have to realize that as you’re watching players and evaluating them for the draft, there are alternatives to your choice,” he says.

Jordan, the Andrews Institute doctor, says the progress made in reducing elbow injuries has been promising, but it’s far from a home run.

“What we’re hoping is that as this message gets out, the kids will have less incidence of overuse, and then we’ll see less incidence in our favorite players at the professional and college levels,” he says.

“It’s a never-ending process. You get one generation kind of figuring out how to do it, and then you’ve got to teach the next.”

WebMD Health News


Tracy Bracken, Georgia District 2 Little League coach.

Sports Health: “Prevention of Elbow Injuries in Youth Baseball Pitchers.”

Steve Jordan, MD, Andrews Institute for Orthopaedics and Sports Medicine.

American Sports Medicine Institute: “Tommy John Position Statement.”

Johns Hopkins Medicine: “Tommy John Surgery (Ulnar Collateral Ligament Reconstruction).”

Major League Baseball: “Just who is Tommy John, and why does everyone talk about his surgery all the time?”

American Journal of Sports Medicine: “Trends in Medial Ulnar Collateral Ligament Reconstruction in the United States.”

Little League Baseball: “Regular season pitching rules.”

USA Baseball news release: “MLB, USA Baseball Recognize Pitch Smart Compliant Organizations.”

National Federation of State High School Associations: “Reducing Pitching Injuries: Count Pitches, Don’t Count on Surgery.”

Guerry Baldwin, president, East Cobb Baseball.

American Journal of Sports Medicine: “Performance, Return to Competition, and Reinjury After Tommy John Surgery in Major League Baseball Pitchers.”

Dave Littlefield, vice president for player development, Detroit Tigers.

The Physician and Sportsmedicine: “Public perceptions of Tommy John surgery.”

Jim Beattie, former Toronto Blue Jays scout.

AARP: “Why Tommy John Is Against the Surgery That Bears His Name.”

CBS Sports: “Marlins’ Braxton Garrett: Ready for redemption. “

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