“We all know that we are in the middle of an epidemic with our youth throwers,” an orthopedic specialist opined in a March editorial. The sports medicine professionals and readers of the journal Arthroscopy may know this, but it is far from common knowledge among parents and coaches in youth baseball leagues.
As scientists and sports fans, we are particularly interested in a scientific, evidence-based approach to injury prevention and sports medicine. As parents, we have a personal investment in youth sports leagues’ approach to injury prevention. Our child has played baseball in three youth leagues, and there has been little oversight or guidance regarding player safety. If our experience is the norm, then it seems most youth baseball players play with little supervision on sports-specific injury prevention, and education and outreach for coaches and parents is insufficient, to put it mildly.
Given the prominence of football and chronic traumatic encephalopathy in the national discourse, parents are now pretty equipped to ask youth sports leagues general questions about concussion and safety protocols. Following Damar Hamlin’s very public commotio cordis episode, parents may also know to find out whether coaches have received training in CPR and using an automatic external defibrillator.
This high-level understanding of sports safety is valuable; however, it does not address baseball-specific injuries. The types of injuries sustained in youth baseball can be categorized as contact injuries — such as concussions, fractures, and contusions — or overuse.
Overuse injuries are more prevalent in baseball, and result from excessive and repetitive bouts of throwing. This can lead to musculoskeletal stresses, fatigue, and pain, further leading to biomechanical changes in throwing motions that could leave players at risk of serious injuries, such as ulnar collateral ligament tears. Stress-related overuse injuries include stress fractures and growth plate injuries. Little is known about the true prevalence and long-term effects of overuse injuries because they are less likely to be reported or identified through surveillance databases. Recent explorations of the consequences of musculoskeletal injuries sustained as youths across the lifespan hint at increased rates of osteoarthritis and limitations in mobility. Similar overuse injuries are also observed in fast-pitch softball. Upper extremity injuries are prevalent in both sports, even with the underhand pitching motion used in softball.
This information is available to anyone who takes the time to conduct a cursory review of the scientific literature. However, it shouldn’t be on parents to raise questions about baseball- and softball-specific injury concerns — they should receive the information, as should players and coaches. There needs to be a concerted outreach effort to disseminate information and educate everyone involved.
Although organizations such as Little League, Pony League, American Legion, or one of several other youth baseball organizations provide oversight for their teams, at the local level, many youth baseball leagues are run by volunteers from the community. In our local youth baseball association, an overwhelming number of kids are eager to don a glove and pick up a bat, and there are barely enough coaches to manage them all. And while official Little League registered organizations require a safety officer on their board, most others, such as Babe Ruth League and Pony League, have no such requirements pertaining to a safety officer. Recreational players are potentially at greater risk of overuse injuries because they don’t get the same guidance and support afforded to elite players in competitive leagues.
In response to alarm from orthopedic surgeons noticing an increase in adolescent patients with elbow injuries, MLB and USA Baseball developed the Pitch Smart program in 2014.
Pitch Smart is a collaborative effort to inform and educate parents, players, and coaches of the limitations of young bodies and to provide guidance regarding pitch counts, types of pitches, the importance of rest, and the dangers of sport specialization on developing children and adolescents. This free resource provides ample guidance from experts representing MLB, USA Baseball, and the American Sports Medicine Institute for best practices in pitching safely, with age-based guidelines for players as young as 7 years old.
Leagues may apply as being recognized as “Full Compliant” or “Select Compliant” with the Pitch Smart guidelines, with accepted organizations then noted as participants in the Pitch Smart Compliance Program. The guidelines are thorough, evidence-based, and approved by orthopedists and physical trainers.
However, the “agreements” for Pitch Smart compliance are made by league officers at a high level and are not conveyed to parents or coaches. Coaches (and parents) must proactively seek out this information, even though it is critical to ensuring player safety. Furthermore, it can be difficult to interpret the guidelines if you do not have previous experience with baseball, coaching, or sports safety.
It’s also unclear how compliance is measured, by whom, or what repercussions a league may face if it does not follow the Pitch Smart suggestions.
So it’s no surprise that there’s no indication the Pitch Smart guidelines are widely disseminated or promoted. In a 2018 survey of youth baseball coaches, only 13% of coaches were able to identify risk factors for overuse injuries correctly. In 2020, it was reported that 58.9% of parents were familiar with pitch count guidelines. A 2021 survey found that only 43% of coaches correctly answered questions regarding pitch count and rest periods. Yet another 2021 survey that specifically addressed Pitch Smart guidelines observed, “Noncompliance with Pitch Smart guidelines in tournament settings occurred in more than 90% of teams and almost half of all pitchers.”
The current situation with softball is even more dire. As with anything related to women’s sports or women’s health, there was a concerning lack of guidance and pitch count limits for softball prior to 2022 recommendations from a top orthopedic sports medicine society.
The lack of awareness of safe pitching practices is alarming. Even more concerning, however, is the silence from MLB in the face of ignorance from coaches and parents. Health misinformation rapidly fills this void. In a 2021 study, researchers found that a Google search for “youth pitching recommendations” returned results from athletic organizations, educational institutions, and commercial entities. Although the educational and athletic organizations provided evidence-based recommendations, only 54.8% of commercial websites provided pitching recommendations aligned with Pitch Smart, according to the study. It’s particularly troubling that the commercial websites selling devices used to measure pitching velocity provide this information. You can imagine a parent going to the website for advice, only to end up buying the device that goes directly against the guidance.
It is not enough for orthopedists and sports medicine professionals to discuss injury prevention among themselves in journals. By the time a young player is meeting with an orthopedic surgeon, it is too late.
Simply hosting a website is insufficient. The Pitch Smart guidance should be widely promoted, to all invested parties at all levels, using the same approach that public health professionals and science communicators use to encourage other preventative measures. MLB must have direct communication with youth baseball leagues, advertisements on MLB.tv and MiLB.tv, and education at MLB and Minor League Baseball games. Signage directing parents and coaches to PitchSmart.org at every amateur baseball facility would be a simple first step. Hosting open question and answer sessions for parents and coaches to attend would be a welcome complement to merely hosting a website.
It is a tragedy when an overzealous coach or competitive parent dampens a child’s enthusiasm for play. Just as tragic is an injury that can interfere with a child’s participation in sports or everyday activities. It’s in everyone’s best interests to ensure our kids can safely play ball.
Stuart Wallace is an injury epidemiologist who studies upper extremity injuries in baseball. Stephanie Springer is a pharmaceutical scientist.