Introduction

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  Eighty-seven percent of their parents report worrying about injury, making this a public health concern.

  
  
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  Education of everyone responsible for protecting the health of the young athlete, including the parents, coach, and sport’s governing body, is critical.

  
  
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  Specific to youth athletes is the additional concern of growth plate disruption.

  
  
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  Sports inherently have risk of injury. Some of this risk is unavoidable, and some of this risk is modifiable.

Sports inherently have risk of injury. Some of this risk is unavoidable, and some of this risk is modifiable. As early as 1993, the American College of Sports Medicine (ACSM) reported that up to half of sports-related injuries are preventable ( ).

Upper extremity injuries range from mild soft tissue inflammation to fractures. Throwing sports, with their repetitive nature, add the complexity of overuse injuries. Specific to youth athletes is the additional concern of growth plate disruption.

Thirty-six million kids, ages 5 to 18 years, are estimated to play organized sports each year. Eighty-seven percent of their parents report worrying about injury, making this a public health concern ( http://www.statisticbrain.com/youth-sports-statistics ). Youth sport participation continues to rise, with one survey by the National Council of Youth Sports ( http://www.ncys.org/pdfs/2008/2008-ncys-market-research-report.pdf ) showing steep rises from 1987 to 2005 coupled with large increases in the number of girls participating.

The reasons children participate vary widely: Some participate because they are having fun, some because their friends do it, some because their parents want them to, and some because they believe it is a pathway to professional sports with its associated fame and fortune. The pressure on these children to excel at sports, particularly in one chosen sport, has created a group of injuries, primarily overuse in nature, that are believed to be the result of this push to specialize in one sport early in life.

Early sports specialization, defined in a recent consensus statement ( ), include youth who participate in organized sports for more than 8 months of the year, participate in just one sport, and are prepubertal. Although there is no evidence that participating in only one sport year round starting at an early age will make an individual a better athlete, the expansion of travel and representative side teams for young athletes continues to push this trend.

Baseball ( ), specifically pitchers, is the throwing sport that has attracted the most attention in both the scientific and lay media, but other throwing sports have similar concerns, particularly in field sports (javelin, hammer, and discus), football (quarterbacks), and softball. In all of these sports, repetitive motions in one shoulder in one direction with large amounts of force are required, and large amounts of practice time are common. As an example, 53 youth windmill softball pitchers underwent three-dimensional high-speed video analysis ( ). These young pitchers were found to generate forces around their elbows and shoulders similar to those of college pitchers. This puts them at high risk for overuse injuries, particularly around the biceps labrum complex, with the added worry about deformation of their bones and growth plate injuries.

In response to the well-documented rising trend of ulnar collateral ligament reconstructions in youth baseball pitchers, which reports more than 2 million participants ( http://www.littleleague.org/Page56014.aspx ) in the Little League system (most recent numbers available are through 2006), organizations such as the American Sports Medicine Institute have partnered with Major League Baseball and USA Baseball to provide guidance through programs such as Pitch Smart ( http://m.mlb.com/pitchsmart ) to reduce the risk of injury. This program provides education for coaches, players, and parents about potential risk factors. It also contains guidelines by age group for allowable pitch counts and rest days.

Outside of Pitch Smart, little exists in the way of formal prevention programs for injuries to the throwing shoulder in youth sports. There is no corollary to the FIFA Marc 11+ ( http://f-marc.com/11plus/home ) ( ) program, designed as a warm-up program based on core stability and eccentric hamstring strength and known to reduce injury for upper extremity throwing shoulder prevention ( ).

A comprehensive list of available injury research prevention in youth sports covers 31 studies, including 17 randomized controlled clinical trials, across a variety of sports, but only three included sports with throwers, and they focused exclusively on lower extremity injuries ( ).

There are anecdotal recommendations available on numerous websites, but none are based on science. Guidelines for youth discus throwers are available online ( ) that divide youth athletes by age, but nothing in those guidelines discusses limitations to practice or competition. Similarly, a variety of recommendations are available about softball pitching but nothing that has been formally developed and evaluated. In 2011, the National Athletic Trainers Association published a position statement on Prevention of Pediatric Overuse Injuries ( ) that recommended greater injury surveillance to identify risk factors and modifications of sport training and conditioning programs in conjunction with coaching education.

To prevent injuries to the throwing shoulder, the most important first step during a preparticipation examination or injury evaluation is a good participation history upon presentation. A clear understanding of the cumulative amount of time spent participating in a given sport, particularly in the same position or practicing the same skill, is critical. Asking questions about level of competition, time spent in competition, and frequency of competition provides invaluable information.

Sports participation has been shown to be hugely important for the maintenance of healthy lives both physically and mentally ( ). Sports participation can be done with an appropriate mix of structured and free play. Early warning signs of too much competition should be part of any physical examination; these signs include excessive complaints of aches and pains, too many visits, and reluctance to attend sporting events. Sports participation should be encouraged, but the level and amount of time spent in competition should be carefully monitored to reduce the risk of injury to throwing shoulders. A conversation with both the athlete and the responsible adult is critical if the time spent participating in structured sports appears excessive. Rest is a critical component of successful sports participation. Free play is another critical part of successful sports participation and is important for social as well as physical reasons.

Growth plate injuries are specific to youth and need careful monitoring because their impact is lifelong. Growth plate injuries are believed to result from skeletally immature bone having excessive repetitive motion ( ). It is important to screen athletes who are at risk for physeal injury to rule out growth plate injury or changes at the time of examination.

Conditioning programs are often absent or inadequate in youth sports. Pre- or in-season conditioning is not something that many youth teams focus on nor do they have the coaching staff to properly supervise. The Marc11+ program takes 20 minutes a day. Recommendations for preseason conditioning may provide an avenue for injury prevention. As young athletes learn new skills that require motor control and strength in positions they are unaccustomed to, conditioning can help reduce the risk of injury. Throwing sports are a particular risk factor because most youths do not have much experience with overhead activities, particularly in the extreme ranges of motion required for throwing, especially with a weighted object (e.g., ball, discus) in one’s hand. A conditioning program that focuses on shoulder strengthening above 90 degrees and eccentric as well as concentric motion bilaterally will impact injury rates due to unidirectional motion. In addition, many youth teams may have a policy of not cutting athletes so that some young athletes may be in a sport that is not appropriate for their body type. For young athletes, a recommendation for a different sport may be the most helpful way to reduce injury.

The most important factors in prevention of injuries to the throwing shoulder are proper technique and appropriate control over the amount of time spent practicing and competing in the sport. Coaching, parent, and athlete education are critical components in successful reduction in the risk of injuries to the throwing shoulder. Educational opportunities are plentiful. Each sport’s governing body has educational programs. Coaching associations offer certifications that all include safe sports participation lectures and youth sports parents are often required to sign forms indicating that they will assist their children in safe sports participation. The National Alliance for Youth Sports ( http://www.nays.org ) was started because of concern about the damage to youths from volunteer coaches.

Injury prevention has to start on the level of the individual athlete, with parents and youths understanding the need to recognize limits. Although large-scale randomized controlled trials can be conducted to determine if a given strategy may reduce rates of injury over time, nothing is more important than sitting with an individual child and fully understanding her or his level of participation and fitness for the sport. Youth sports are unlikely to have access to appropriate medical care that can supervise formal prevention programs, so individual plans have the most benefit.