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CU Sports Medicine

CU Sports Medicine

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18-innings and 560+ Pitches Equals Serious Shoulder Work

CU Sports Medicine and Shoulder surgeon, Dr. Jonathan Bravman, discusses shoulder overuse and how to avoid injury

Dr. Jonathan Bravman
Aurora, CO | November 1, 2018

The 2018 World Series was, like all the rest, a battle of the best. Teams play through nerves, fatigue, and injuries in the unrelenting pursuit of that championship title. However, this years’ Game 3 proved to be monumental with a record 18-innings; the most for a postseason game in the history of major league baseball. We began to wonder about the pitcher? An average 9-inning game can see five pitchers who, combined, will throw around 150 times. Now double that (still talking average numbers here) and we get an 18-inning game for a whopping 300 pitches thrown. However the 2018 World Series Game 3 saw a record number 18 pitchers used with over 560 pitches! Granted that was split between 9 pitchers on each team, but not equally. Starting pitchers will shoulder the majority of  pitches with the expectation of a few days rest before the next game…unless of course you’re playing in the World Series and the next game happens to be, the very next day

We wanted to know how, with this incredible work load, do pitchers keep themselves in top performance to avoid injury? To get the answer, we reached out to University of Colorado orthopedic sports medicine and shoulder surgeon, Dr. Jonathan Bravman. 

From your perspective of over-use, what do you begin to worry about in such a long game?
Obviously, with such a long game, both teams’ rosters (especially pitchers) will be stretched to their max – in a typical regular season situation with a 5 pitcher rotation and several relief pitchers, this is not an issue. What becomes the problem, is when we start to look at pitch counts and what each member of the pitching core is being asked to do. A game length like we saw in Game 3 calls upon all of the athletes to throw much more than is typical. These situations, when muscular fatigue sets in, and throwing mechanics may begin to break down in order to continue to perform, is where we really worry injuries will occur and recovery will be a difficult task with back to back games scheduled. 

You mention relief pitchers and back-to-back game schedules; if they all see action in a long, demanding game, how do they make the decision to play the next day?
The staff get to know the players extremely well and the players get to know themselves well in how they will feel both the day after they throw and also two-three days after. This is what they are training and preparing for all year – I would guarantee that not one of these players would pass up the opportunity to play and contribute in the World Series (provided they feel good and are ready to play). Things they will focus on are recovery measures such as a cool down routine, ice bath and therapy modalities (massage, stretching and treatments by the athletic training staff) as well as a very good warm-up to ensure they are loose and ready to perform when called upon. Most all pitchers perform a consistent and thorough rotator cuff routine on all off days which we think helps them stay strong, recover well and avoid injury all while able to perform at their maximum potential.

What’s the most common injury you see from overuse?
The majority of “overuse” injuries will be a tendonitis or strain of the muscle/tendon unit. This can be both in the shoulder or elbow and different populations have different patterns of injury with several injuries unique to the younger, skeletally immature athlete. We see many problems with scapular (shoulder blade) mechanics – called dyskinesia – and thankfully the majority of these problems can be successfully treated with a period of rest and focused, supervised physical therapy.

Any signs that would point more toward a strain vs a tear?
Thankfully most injuries in this realm with not be “tears” (either of the labrum or rotator cuff in the shoulder or UCL – the “Tommy John” ligament – in the elbow) and will be amenable to rest and recovery without requiring surgery. Nothing supplants a good history and physical exam by a trained sports medicine specialist, though weakness and the degree to which the athlete is injured are good guidelines that help us determine the severity of these injuries. We often ultimately rely on MRI to help confirm our clinical diagnoses in an effort to help guide optimal treatment.

How do you recommend protecting your shoulder/elbow from overuse?
Post-game recovery modalities with an adequate period of rest is critical. A thorough and complete warm-up when they do get called on to pitch again is also critical. The methods most players use to avoid injury in general are monitoring pitch counts and performing a “shoulder program” that they perform most days they are not playing. Rotator cuff strengthening, shoulder stretching and a focus on mechanics are critical at all levels.

Where we see this to be a critical issue and really an epidemic, is in little league baseball. The AOSSM has published well-established guidelines including pitch counts, minimum periods of rest between pitching episodes, suggestions on rotating positions as well as age limits for the most demanding pitches. All to assist in avoidance of overuse shoulder and elbow injuries which is critical for both our professional and little league players alike.


For more information, contact: 
Anschutz Medical Campus, Academic Office 1
12631 E. 17th Avenue, Mailstop B202,
Aurora, CO 80045

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