Baseball Elbow Hand Sports Injury

Advice from a Certified Hand Therapist: Treating Tommy John Injuries

Baseball season is in full swing for the pros. Unfortunately, for many youth baseball players, summer leagues are just one of the year-round seasons they play. A Tommy John injury (injury of the ulnar collateral ligament at the elbow) was unheard of in youth leagues in the mid-90s. By 2010, the adolescent rate was nearly 40 percent. As a baseball enthusiast, I find this trend disturbing. I asked Dr. Bobby Chhabra, Chair of the Orthopedic Department at the University of Virginia, his perception of this epidemic.

“Every year I see more and more adolescent elbow injuries from pitching and throwing. These injuries vary across a spectrum from little leaguer’s elbow, to muscle strains, to UCL injuries (Tommy John), and cartilage injuries. I would agree that the adolescent rate is increasing and the trend shows that this group may soon reach half of all surgeries performed to repair a Tommy John injury. 

The reasons for this are likely multi-factorial but include the increasing number of kids who play one sport and pitch year round from a young age, have poor mechanics, have fatigue leading to poor mechanics and injury, and have overuse with minimal rest.  

Unfortunately, I am performing elbow surgery on more and younger players each year.  During my discussions with these young pitchers and their parents, I try to educate them on why this injury has happened and stress the importance of avoiding overuse after the surgery and really focusing on the correct bio-mechanics of throwing. I stress the importance of these pitchers ‘listening to their bodies and elbows’ and knowing when they are fatigued and not hesitating to tell their coaches that they need to rest.  

It is important for these young pitchers to work with experienced therapists or a team of rehab experts who can not only help with muscle strengthening and flexibility, the standard recovery protocol, but also educate these pitchers on the correct mechanics.  Education on how to avoid overuse, fatigue, and recurrent injury, routine strength and flexibility training, appropriate rest between throwing sessions, limiting pitches per inning and the number of innings pitched in a season, and a focus on correct throwing mechanics are all critical in maximizing the outcome of an elbow UCL reconstruction surgery.”

As a certified hand therapist, I see these injuries for treatment both before and after surgery. I refer players and parents to the Position Statement for Tommy John Injuries in Baseball Pitchers by the American Sports Medicine Institute for additional information. This statement focuses on the real heart of the issue – pitch less and with lower velocity and injuries will go down. In addition, careful management of individual pitcher’s fatigue level is imperative. For pitchers, studies have shown that this is much more important than the type of pitches thrown. Initially, it was thought throwing curve balls and breaking balls was the culprit. Dr. Chhabra has a theory about this:

“Numerous studies have not been able to prove that curve balls or breaking balls increase the risk of shoulder of elbow injuries in adolescent pitchers.  I agree with this.  However, these young pitchers who can throw curve balls and breaking balls and have a wider range of pitches are likely the elite pitchers on their teams and tend to be relied on more. So they may pitch more innings and more frequently.  This can lead to fatigue, poor throwing mechanics, overuse, and ultimately to shoulder and elbow injuries.  It is important to recognize that while types of pitches may be a small reason for a shoulder and elbow injury, the major contributors to injury in pitchers are the amount of pitching without adequate rest, the number of pitches thrown in an inning, the number of innings thrown in a season, months pitched per year, velocity of pitches, and poor pitching mechanics.” 

I agree with Dr. Chhabra that the risk factor with the strongest correlation to injury is amount of pitching. 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. Improper biomechanics may increase the torque and force produced about the elbow during each pitch.

It has become evident to me that we can gain more by empowering coaches to teach proper bio-mechanics, limit innings/pitches and consider encouraging athletes to rest between seasons by either changing position or pursuing a different sport in the off season. Stop Sports Injuries provides resources for young athletes, coaches, parents and healthcare providers promoting safe participation in sports.


Jeff Smith, OT, CHT is a Certified Hand Therapist and a member of the American Society of Hand Therapists. Dr. Bobby Chhabra is a member of the American Society for Surgery of the Hand and is the Chair of the Department of Orthopedic Surgery at the University of Virginia.

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