One, Two, Three Strikes You’re Out at the Old Ball Game

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August 16, 2018

By Jeremy D. Howard, MS, LAT, ATC

The song “Take Me Out to the Ball Game,” sunflower seeds and red clay are just a few of the defining aspects that make baseball a great American pastime. However, this sport is not without its own unique risks for injury.

During a recent epidemiological study, injury rates from United States High School-level baseball players from the 2005-2006 to the 2014-2015 athletics seasons for baseball were evaluated. Injury rates stood out for both the shoulder at 1.39 per every 10,000 athletic exposures and the elbow at 0.86 per every 10,000 athletic exposures for which most occurred in game-like scenario over practice (Saper, Pierpoint, Liu, Comstock, Polousky, & Andrews, 2017). Saper et al stressed that pitchers were most likely to sustain these injuries noting that pitcher shoulder injuries came in at 39.6% of all shoulder injuries and pitcher elbow injuries came in at 42.7% of all elbow injuries sustained by baseball athletes. Further, Melugin, Leafblad, Camp, and Conte (2018) noted the drastic increase in surgical elbows for ulnar/medial collateral ligament injury. Taking in to account this striking data and understanding the drastic repercussions of ulnar collateral ligament repair or ‘Tommy Johns’ surgery and their potential for medical disqualification of the athlete from play, it quickly becomes apparent that we, as Athletic Trainers (ATs), need to be proactive and not just reactive to keep the kids playing the game they love!

Medical disqualification from sport can be catastrophic news for someone who identifies with their athletic prowess on the baseball diamond. Saper et al noted that of the aforementioned elbow and shoulder injuries, just shy of twice as many elbows compared to shoulder injuries resulted in the dooming news of medical disqualification for pitchers. This should scream to us, as healthcare providers, that we need to figure out how to better protect our athletes. Thus, a strong jumping off point for our profession may be to first understand what pitch holds the most potential for injury.

Luckily, a recent study by Makhni, Lizzio, Meta, Stephens, Okoroha, and Moutzouros (2018) looked at the torque applied to the elbow during a pitching sequence of various types of pitches including the fastball, the curveball and the change-up. Their findings suggested the fastball led the way with torque inflicted upon the medial elbow at 45.56 Nm, likely associated to the effects of velocity on torque about the medial elbow. Just imagine the stresses placed upon the UCL during that single maximum effort fast ball. Then, take into account the pitch counts of these athletes per game, and the various year-round seasons of fall, spring and summer baseball and the perfect storm is quickly forming. Without an intervention under those conditions eventually something will fail.

Now, what does that mean to ATs working in a Sports Medicine Department or for a baseball team? Melugin et al posited some concepts and best practices in injury prevention that can help better protect our pitchers. It was suggested youth pitchers should first learn and obtain consistency in proper fastball mechanics and should not pitch competitively for more than 8 months in a given year. Gabbett (2016) added with his suggestion that pitchers receive injury prevention and sport performance benefits from using graded training volume approaches particularly with any activity that includes an external load, such as pitching, as the higher the pitch counts the higher associated rates of injury. Gabbett posited that using a session-based Rated Perceived Exertion Scale (on the 10-point scale, not the 16-point scale) to establish an athlete’s preparedness to perform and avoid injury on the mound would assist in awareness of their ability to perform that day and indirectly assist in injury prevention efforts. Finally, Saper et al after examining the epidemiology of injury for baseball, advised that the best practice in injury prevention would be fatigue limitation and addressing common overuse injury areas in advance. The key takeaway here for ATs seems to be a focus on ensuring mechanics are right and the patient receives adequate rest and recovery. Knowing pitchers are the most common victim of injury in baseball, it seems this can be achieved by working hand-in-hand with the team’s pitching coach to establish a trusting and respectful relationship.

So, what can be done once ATs have obtained the coach’s buy-in on injury prevention? Various well-established programs can be considered for inclusion to help prepare the pitcher’s shoulder for performance. Two well-known injury prevention programs address overuse concerns and they are the ‘Throwers Ten (Beginners and Advanced)’ and the ‘Ballistic Six. ’ Both have been looked at in research for their effectiveness in both performance outcomes and injury prevention.

Myers, Toonstra, Smith, Padgett, and Uhl (2015) examined the effects of the ‘Thrower’s Ten’ program on muscular endurance and isometric strength of shoulder stabilizers. They found that both the beginners and advanced versions of the program resulted in increases of angular torque and impulse control but noted there were no notable increases in strength or endurance about the shoulder. Two other groups of researchers looked at the ‘Thrower’s Ten’ program and suggested it is effective in relieving pain and was best suited for implementation in rehabilitation programs post-injury (Hazar & Baltaci, 2014; Wilk, Arrigo, Hooks, & Andrews, 2016).

Meanwhile, Carter, Kaminski, Douex, Knight, and Richards (2007) examined the ‘Ballistic Six’ program and found the program to be a strong supplement to the off-season program of the athlete to increase performance and to strengthen the rotator cuff group; they also went on to suggest that the program positively affected upper extremity proprioception and power. However, Carter et al also noted that there was no notable changes seen when compared with a standardized strength and conditioning protocol in the highly trained population. An important take away from this research appears to suggest that both protocols have a proper place, be it in rehabilitation and return-to-play or in off-season conditioning, as a reference for the ATs and pitching coaches to better prepare their pitchers for the mound.


Carter, A.B., Kaminski, T.W., Douex Jr, A.T., Knight, C.A., & Richards, J.G. (2007). Effects of high volume upper extremity plyometric training on throwing velocity and functional strength rations of the shoulder rotators in collegiate baseball players. Journal of Strength and Conditioning Research, 21(1), 208-215.

Gabbett, T.J. (2016). The training-injury prevention paradox: Should athlete be training smarter and harder?. British Journal of Sports Medicine, 0, 1-9. doi: 10.1136/bjsports-2015-095788.

Hazar, Z., & Baltaci, G. (2014). Effects of “Throwers Ten” exercise program on pain and function in shoulder impingement syndrome. Orthopaedic Journal of Sports Medicine, 2(11), Supplement 3. doi: 10.1177/2325967114S00153.

Makhni, E.C., Lizzio, V.A., Meta, F., Stephens, J.P., Okoroha, K.R., & Moutzouros, V. (2018). Assessment of elbow torque and other parameters during the pitching motion: Comparison of fastball, curveball, and change-up. Arthroscopy, 34(3), 816-822.

Melugin, H.P., Leafbald, N.d., Camp, C.L., & Conte, S. (2018). Injury prevention in baseball: From youth to the pros. Current Reviews in Musculoskeletal Medicine, 11, 26-34. doi: 10.1007/s12178-018-9456-5.

Myers, N.L., Toonstra, J.L., Smith, J.S., Padgett, C.A., & Uhl, T.L. (2015). Sustained isometric shoulder contraction on muscular strength and endurance: A randomized clinical trial. International Journal of Sports Physical Therapy, 10(7), 1015-1025.

Saper, M.G., Pierpoint, L.A., Liu, W., Comstock, D., Polousky, J.D., & Andrews, J.R. (2017). Epidemiology of shoulder injuries among United States high school baseball players: School years 2005-2006 through 2014-2015. American Journal of Sports Medicine, 46(1), 37-43. doi: 10.1177/0363546517734172.

Wilk, K.E., Arrigo, C.A., Hooks, T.R., & Andrews, J.R. (2016). Rehabilitation of the overhead throwing athlete: There is more to it than just external rotation/internal rotation strengthening. Physical Medicine & Rehabilitation, 8, S78-S90. doi: 10.1016/j.pmrj.2015.12.005.


About the Author

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Jeremy Howard is the State Health Promotion Officer for Florida Army National Guard under the Resilience, Risk Reduction, and Suicide Prevention Program. Howard graduated with a Bachelor of Science in Athletic Training from Florida Gulf Coast University (#DunkCity) and from the University of Saint Augustine for Health Sciences’ Master of Health Science in Athletic Training programs. He is currently pursuing an Educational Doctorate in Health Sciences at the same institution. In 2002, Howard enlisted in the Florida Army National Guard and is still currently serving; he is also a veteran of Operation Enduring Freedom-Afghanistan. His professional interests include Concussion/TBI, Injury Prevention Programs and Manual Therapy.

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