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08/12/08 10:27 PM ET

Big league surgeries for Little Leaguers

Multitude of factors point to pitchers' injury 'epidemic'

Brian Conway was a star.

Every coach of a traveling baseball team in metro New York longed to have a boy like Conway pitch for him, and Conway accepted offers. He loved being a star, somebody strong of arm and willing to lend his arm anywhere that it was needed.

"I think I pitched three times a week, sometimes more than that," he said. "I'm not sure."

With a fastball clocked in the low 70s, a slider and an overhand curve that dropped faster than a shot put, he had the stuff that boys build dreams about baseball on.

But for a 14-year-old right-hander like Conway, baseball dreams should come with a surgeon's warning label: fragile, handle with care.

Four years and one Tommy John elbow reconstruction surgery later, Brian Conway, four months shy of 19, laments how careless he was with his baseball gift.

"I was stupid," he said. "It was completely stupid. I don't give the blame away; I take most of it myself."

Yet Conway, a soon-to-be freshman at Adelphi University in New York, didn't do anything that other boys and teenagers haven't done the past two decades. The intoxicant they call baseball has lured them toward risks that no Major Leaguer would dare take.

The consequences have been a tripling in the number of elbow reconstructions -- or Tommy John ligament replacement surgeries -- among ballplayers 18 years of age and younger in the past decade or so, said Dr. Joshua S. Dines, an orthopedic surgeon who performed Conway's procedure.

"It used to be pretty rare," said Dr. Dines, a sports medicine physician with the Hospital for Special Surgery in New York. "It was kind of reserved for college or professional players, and now we definitely see a lot of high-schoolers that are coming in with ulnar collateral ligament tears."

The medical literature on Tommy John surgery backs up Dr. Dines. The number of teenagers who have undergone the procedure increased so markedly that, according to a research study presented last month during the annual gathering of the American Orthopaedic Society for Sports Medicine, some medical authorities are now calling the problem an "epidemic."

Little League World Series

"On a certain setting," Dr. Dines said, "it really is."

The problem has not gone unnoticed. Physicians like Dr. Dines have put the problem under a microscope, and their research identifies a chief culprit: overuse of the arm.

These experts can find plenty outside the coaching ranks who agree. They say less is really less, particularly for the youngest of pitchers.

More simply risks problems, said Jason Sekany, a former Minor League pitcher and the owner/instructor of The Pitching Center in Pleasanton, Calif.

"I've seen what I believe are arm problems in younger kids in the 11- and 12-year-old range," Sekany said. "I would definitely say that."

The problem of overuse has caught the attention of Little League Baseball Inc., which has taken steps to limit how often a youngster can pitch.

For the World Series last summer, the Little League slapped a strict pitch count on youngsters, said Stephen D. Keener, president of the organization. Keener said the organization consulted physicians and medical professionals about safety issues, and they warned of seeing a surge in arm surgeries among youth.

"Those professionals who certainly understand the physiological aspect of kids playing the game were saying that kids were throwing too much; pitchers were being overused," Keener said. "At young ages, they're just not mature enough and strong enough yet, physically, to maintain the rigors of throwing like they might when they get college or even in the professional ranks."

"It used to be pretty rare. It was kind of reserved for college or professional players, and now we definitely see a lot of high-schoolers that are coming in with ulnar collateral ligament tears."
-- Dr. Joshua S. Dines on the rise of injuries in Little League pitchers

With the red flag waved, Little League changed from an innings limit (six) to a pitch count. No Little Leaguer can throw more than 85 pitches in a game, a total that a pitcher would routinely surpass in four innings.

Keener said it wasn't uncommon to see pitchers complete a game at the World Series and throw 125 to 135 pitches.

Medical experts said any pitch total that approaches 100 was way too high for a young, fatigued arm to throw in one outing. Keener said that Little League settled on 85 as a total that would satisfy most safety concerns after it weighed a higher and a lower figure.

But Keener still can't be certain whether an 85-pitch limit is a proper benchmark. Any harm a boy causes his arm through overusing it during a Little League game might not display itself until years later.

Overuse is an injury that time reveals.

Yet as worrisome as overuse is, Dr. Dines can point to other risk factors as well. One factor that he cites is the lack of proper rest between each outing. Another is improper throwing technique, something that training centers like Sekany's try to correct.

Still a third is the breaking ball, a pitch Dr. Dines wishes Little Leaguers didn't throw.

"They should stick to fastballs -- and maybe a changeup," Dr. Dines said. "As you get older and you have muscle control and your arm is stronger, you can then start working in things like sliders and curveballs."

Keener has heard calls for outlawing breaking balls in the Little League. While he didn't discount the risk posed in throwing curveballs and sliders, he doesn't see a simple way that those pitches can be banned.

The enforcement of such a ban would be problematic.

"To put that onus on an umpire behind the plate -- who's also a volunteer -- could be quite difficult," he said.

To acknowledge the riskiness of breaking balls, he recommends, too, that youngsters don't throw it, but he also said he's seen no conclusive data that positively point out that throwing curveballs causes problems for a boy's arm.

Sekany doesn't see as much reason to worry about the curveball as others do. He said the pitch has become a scapegoat that critics point to and that it shouldn't be.

He thinks that proper technique keeps the curveball from putting undo stress on a developing arm. But what does worry him is a risk factor that Dr. Dines puts the spotlight on: improper rest between outings.

Time and again, he hears tales about youngsters, often playing on two or three elite teams, pitching on back-to-back nights. They want to take a day's rest, but they dare not let their coach or their team down, Sekany said. They will pitch in pain if they're asked to pitch.

He calls it foolish to put a boy's arm at risk, when no one would think to risk the arm of a grown man. Major League Baseball, he said, should be the example to follow: rest a pitcher's arm or wear the arm out.

Brian Conway, who's played Little League and organized baseball since he was 7, never rested his arm. He wore it out.

The throbbing pain in his arm was bearable at 13.

"I would say it was more like a headache," Conway said. "It was an annoying pain, but I knew it would go away. It didn't ruin my day."

As he neared 14, the pain worsened. As it did, he found yet another traveling team to join and yet another opportunity to pitch and play the star's part.

"Being so young, I was kinda attracted to being the All-Star," he said. "I was pitching for every team."

He often mentioned to his coach that his arm ached, but the coach had no way of knowing how many pitches Conway had thrown the night before for another coach's team.

"He'd say, 'Can you give me a few innings?' " Conway said. "A few would turn into four or five."

But nothing assures an appointment with a Tommy John surgeon better than a pitching schedule like Conway's.

"Not only was I playing in too many leagues, I wasn't getting my rest," said Conway, the hint of regret in his tone. "When I was pitching for one team, my day of rest for that team was pitching for another team.

"It was totally a bad decision on my part."

As he heads to college in a few weeks, Conway wonders aloud if he should play baseball there. He's never stopped liking or playing the game since Dr. Dines performed Tommy John surgery on Nov. 22, 2004.

Brian Conway was 14 then. He hasn't pitched since.

Justice B. Hill is a reporter for MLB.com. This story was not subject to the approval of Major League Baseball or its clubs.